Clinicians' implicit ethnic/racial bias and perceptions of care among Black and Latino patients

Regional trends and disparities in newer GLP1 receptor agonist initiation among real-world adult patients eligible for obesity treatment

AIMS

To characterize trends in the initiation of newer anti-obesity medications (AOMs) and determine factors associated with their use among obese/overweight populations.

MATERIALS AND METHODS

This study utilized electronic health record data from OneFlorida+ (2015-2024). Adults eligible for AOMs were included, defined as having a body mass index (BMI) ≥30 kg/m2 or a BMI of 27-29.9 kg/m2 with at least one obesity-related comorbidity. The primary outcome was the initiation of newer AOMs, specifically glucagon-like peptide-1 receptor agonists (GLP-1 RAs) including liraglutide, semaglutide and tirzepatide. Trends across years were examined, and a multivariable logistic regression identified sociodemographic, clinical and healthcare utilization factors associated with AOM initiation.

RESULTS

Of 319,949 adults, 1.8% initiated newer AOMs. Semaglutide accounted for 77.9% of initiations, tirzepatide 19.7% and liraglutide 17.8%. Initiation trends showed liraglutide uptake peaked at 5% in 2018 but declined afterward, while semaglutide and tirzepatide uptake increased exponentially since 2022. Odds of initiation were lower for Black (aOR [95% CI]: 0.87 [0.80-0.94]) and Hispanic (0.84 [0.78-0.91]) groups versus Whites, and for Medicaid (0.69 [0.63-0.76]) and uninsured (0.81 [0.74-0.87]) patients versus privately insured. Higher odds were associated with being female, middle-aged, having more outpatient visits and visiting endocrinologists.

CONCLUSIONS

The initiation of newer AOMs among overweight and obese populations remains low, but uptake has increased exponentially since 2022. Our findings reveal significant disparities in obesity care, highlighting the importance of addressing inequities in AOM access to improve obesity outcomes.

Understanding Health Care Disparities: A Focus on Diverse Women

As primary care clinicians, it is important to recognize the causes of health disparities in our patients who are women of color in order to advocate and work toward true equity in health outcomes. This article strives to introduce this concept by presenting areas of inequity such as maternal mortality, management of pain, cardiovascular health, and breast cancer outcomes. Lastly, we will introduce a framework and actionable steps that can be taken to counteract the biases known to influence patient care.

Psychosocial stress and cardiovascular disease

Mahatma Gandhi once famously said: "poverty is the worst type of violence". He was referring to the state of political and social unrest that was pervading his nation, and the impact that humiliating defeat had on those who suffered in dire straits. Today, there is mounting evidence that social disparities cause intense psychosocial stress on those on whom they are imposed and can result in adverse cardiovascular outcomes. In modern society we still witness large disparities in living conditions between races, regions, continents and nations. Even in more privileged nations, we often witness the existence of "food and social deserts" in the middle of large urban centers. Sizable segments of the population are deprived of the comforts and privileges enjoyed by others; food quality and choices are limited, opportunities to exercise and play are scarce or unsafe, physical and verbal violence are prevalent, and racially driven conflicts are frequent. It has become apparent that these conditions predispose to the development of cardiovascular disease and affect its outcome negatively. Besides the increase in incidence of traditional risk factors, such as smoking, hypertension, insulin resistance and obesity, several other pathophysiological mechanisms involving the neuro-endocrine, inflammatory and immune pathways may be responsible for the noted negative outcomes. In this manuscript we review some of the evidence linking social distress with adverse cardiovascular outcomes and the potential subtending mechanisms and therapeutic interventions.

Comparative analysis of influenza healthcare disparities in the United States using retrospective administrative claims from Medicaid and commercial databases, 2015-2019

BACKGROUND

Influenza-related healthcare utilization among Medicaid patients and commercially insured patients is not well-understood. This study compared influenza-related healthcare utilization and assessed disease management among individuals diagnosed with influenza during the 2015-2019 influenza seasons.

METHODS

This retrospective cohort study identified influenza cases among adults (18-64 years) using data from the Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) Research Identifiable Files (RIF) and Optum's de-identified Clinformatics® Data Mart Database (CDM). Influenza-related healthcare utilization rates were calculated per 100,000 patients by setting (outpatient, emergency department (ED), inpatient hospitalizations, and intensive care unit (ICU) admissions) and demographics (sex, race, and region). Rate ratios were computed to compare results from both databases. Influenza episode management assessment included the distribution of the index point-of-care, antiviral prescriptions, and laboratory tests obtained.

RESULTS

The Medicaid population had a higher representation of racial/ethnic minorities than the CDM population. In the Medicaid population, influenza-related visits in outpatient and ED settings were the most frequent forms of healthcare utilization, with similar rates of 652 and 637 visits per 100,000, respectively. In contrast, the CDM population predominantly utilized outpatient settings. Non-Hispanic Blacks and Hispanics exhibited the highest rates of influenza-related ED visits in both cohorts. In the Medicaid population, Black (64.5%) and Hispanic (51.6%) patients predominantly used the ED as their index point-of-care for influenza. Overall, a greater proportion of Medicaid beneficiaries (49.8%) did not fill any influenza antiviral prescription compared to the CDM population (37.0%).

CONCLUSION

Addressing disparities in influenza-related healthcare utilization between Medicaid and CDM populations is crucial for equitable healthcare access. Targeted interventions are needed to improve primary care and antiviral access and reduce ED reliance, especially among racial/ethnic minorities and low-income populations.

Attachment as a Primary Mechanism in Physician Cognition and Bias During Complex Medical Cases: A Narrative Review

Introduction

In recent decades, improvements in diagnostic accuracy in medical cases have been minimal despite rapid advancements in technology. Moreover, in complex cases, diagnostic accuracy remains a significant challenge, often reflecting practices from the 18th and 19th centuries. This comprehensive narrative review explores how cognitive bias may act as a critical, yet neglected, factor contributing to the persistent diagnostic error rate.

Methods

A narrative review of the literature was conducted through a search of the George Washington University library databases and Google Scholar to identify studies related to physician cognition, complex medical diagnosis, and cognitive error.

Results

This review synthesizes existing literature to propose a theoretical framework explaining how cognitive error, clinician cognition, tolerance of uncertainty, and attachment theory interact to influence the formation of cognitive bias at the cost of diagnostic accuracy and efficiency.

Discussion

It is not only necessary for clinicians to focus on a patient's words, symptoms, or data to improve diagnostic accuracy, but also for clinicians to relate to others' distress through their own attachment styles: technology's critical blind spot. Clinicians with insecure attachment styles may struggle with metacognition, exhibit lower cognitive flexibility, have reduced tolerance for uncertainty, experience lower thresholds for cognitive load, and rely more heavily on heuristics, leading to an increased likelihood of cognitive error during complex medical cases. This theory provides a foundation for further research into how attachment influences clinician decision-making and diagnostic performance while also highlighting how medical education may reinforce these patterns.

Assessing the efficacy of a hybrid closed loop system in a racial-ethnic minority cohort of children and adolescents with type 1 diabetes

OBJECTIVES

Despite improved outcomes in the use of a hybrid closed loop system (HCLS), significant disparities in the application of this technology exist among youth with type 1 diabetes (T1DM). The study aimed to evaluate the impact of a tubeless HCLS on glycemic outcomes in a pediatric racial-ethnic minority population.

METHODS

A retrospective, single-center study included youth with T1D initiating HCLS Omnipod 5. Outcomes included HbA1c, continuous glucose monitor variables, BMI Z score, and episodes of diabetic ketoacidosis (DKA). Outcomes were compared from baseline, 3 and 6 months of Omnipod 5 start.

RESULTS

The study included 174 participants, aged between 2 and 22 years, with a mean age of 7.9 ± 3.7 years. Hispanics constituted 87.3 % (152) of the cohort, with 53 % males and 47 % females. Insurance coverage was 56.9 % public, 42.5 % private, and 0.5 % uninsured. Baseline HbA1c level was 8.0 % ± 1.7, 7.3 % ± 1.1 at 3 months and 7.3 % ± 1.1 at 6 months (p<0.001). Glucose time in range (TIR) was 54.5 % at baseline to 61.9 % at 3 months, and 60.5 % at 6 months (p<0.001). Notably, there were no changes in BMI z-scores or DKA episodes following the initiation of the HCLS Omnipod 5.

CONCLUSIONS

The study showed that a tubeless HCLS significantly improved glycemic control in a pediatric minority cohort with T1DM, without affecting BMI Z-scores or increasing DKA episodes. Ongoing efforts to address disparities in diabetes technology access are crucial for optimizing care and alleviating the burden on individuals with T1DM across racial backgrounds.

The effect of media aids in genetic carrier screening education among patients with infertility

Objective

To evaluate the effect of educational videos on the utilization of preconception genetic carrier screening in patients with infertility.

Design

Survey study.

Subjects

New patients presenting for infertility consult with one of five providers (4 physicians and 1 nurse practitioner) from November 2021 through February 2022.

Exposure

Patients were assigned to the web application EngagedMD video arm or in-person counseling arm for education on preconception genetic screening.

Main Outcome Measures

The primary study outcome was completion of genetic carrier screening. The secondary outcomes were provider rating of patient comprehension and provider-rated time demand of counseling.

Results

A total of 73 patients were enrolled: 42 in the video arm and 31 in the in-person counseling arm. The survey response rate was 100% for patients and providers. Patients assigned to the video counseling arm were significantly more likely to plan to proceed with carrier screening (78.6%) than those receiving only in-office counseling (41.9%). The odds ratio associating video arm with actual completion of screening was 5.07 (95% confidence interval, 1.84-13.96). Patients who completed EngagedMD videos were perceived by providers to have a noninferior understanding of the purpose of carrier screening compared with those who underwent standard counseling, assessed via "teach-back" method. Providers also rated that multimedia education use significantly decreased demand on appointment time.

Conclusion

The use of patient education videos increases utilization of preconception genetic carrier screening and is an acceptable alternative to in-person provider counseling.

Increased Time to Fixation After Traumatic Spinal Cord Injury Influenced by Race and Insurance Status

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

Although the optimal timing of surgical intervention for traumatic spinal cord injury (TSCI) is controversial, early intervention has been recognized as being beneficial in several studies. The objective of this study was to evaluate the socioeconomic factors that may delay time to surgical fixation in the management of TSCI.

METHODS

The present study utilized the Trauma Quality Improvement Program (TQIP) dataset to identify patients aged greater than 18 undergoing spinal fusion for TSCI from 2007-2016. Patients were divided into subgroups based on race and insurance types. Multivariable linear regression was used to compare time to procedure based on race and payer type while adjusting for demographic and injury-specific factors. Significance was set at P < .05.

RESULTS

Using multivariable analysis, Hispanic and Black patients were associated with significantly increased time to fixation of 12.1 h (95% CI 5.5-18.7, P < .001), and 20.1 h (95% CI 12.1-28.1, P < .001), respectively compared to White patients. Other cohorts based on racial status did not have significantly different times to fixation (P > .05). Medicaid was associated with an increased time to fixation compared to private insurance (11.6 h, 95% CI 3.9-19.2, P = .003).

CONCLUSIONS

Black and Hispanic race and Medicaid were associated with statistically significant increases in time to fixation following TSCI, potentially compromising quality of patient care and resulting in poorer outcomes. More research is needed to elucidate this relationship and ensure equitable care is being delivered.

Painful Subjects, Desiring Relief: Experiencing and Governing Pain in a Medical Cannabis Program

Cannabis can provide patients benefits for pain and symptom management, improve their functionality, and enhance their well-being. Yet restrictive medical cannabis programs can limit these potential benefits. This article draws on four years of research into Minnesota's medical cannabis program-one of the most restrictive in the United States-including in-depth interviews with patients and a survey of health care professionals. Drawing on the new materialist concepts of Deleuze and Guattari, this article analyzes (a) the benefits patients in Minnesota's medical cannabis program derive from cannabis, (b) how program restrictions mediate access to cannabis and its derived benefits, and (c) some key ways in which medical and criminal justice institutional authorities are reconfigured around medical cannabis. I show how the imperative to authoritatively govern "dangerous drugs" persists in consequential ways as the War on Drugs shifts toward a medicalized, criminalized, and commercial-legalized mixed regime.

Ethnic Disparities in Patient-Centered Communication with Healthcare Providers: A Comparison of Non-Hispanic Asians and Non-Hispanic Whites

BACKGROUND

Patient-centered communication (PCC) is an important metric related to patient health outcomes. Non-Hispanic Asian (NHA) individuals reported lower PCC scores with healthcare providers than individuals of other races and ethnicities. We aim to determine the ethnic disparities in PCC and further investigate the association between PCC, individual's confidence in obtaining health-related information (health literacy), and confidence in taking care of themselves (health self-efficacy) among NHA in comparison to the Non-Hispanic White (NHW) population.

METHODS

This is a cross-sectional study. We used data from the Health Information National Trends Survey 5 (HINTS) cycles 1 and 3. PCC was measured using seven validated survey questions with scores ranging from 7 to 28. Individuals' health literacy and self-efficacy were accessed using two-item survey questions. Multivariable logistic regression analyses were performed to determine the association of independent factors (e.g., self-efficacy, health literacy, and race and ethnicity) with PCC.

RESULTS

We included 3,831 participants. Fewer NHAs (35.43%) reported high PCC scores compared to NHWs (48.99%, p = 0.0184). In fully adjusted logistic regression model, although NHAs were less likely to have high PCC scores (aOR = 0.78, 95% CI 0.46-1.32) compared to NHWs, the association was not statistically significant (p = 0.350). However, the aOR of confidence in self-efficacy associated with high PCC scores was 2.27 (95% CI 1.68-3.07, p < 0.001) and the aOR of confidence in health literacy with high PCC scores was 2.13 (95% CI 1.64-2.76, p < 0.001).

CONCLUSIONS

High PCC scores reported by NHA were not significantly different from those of NHW individuals in adjusted comparisons. Individual's confidence in self-efficacy and health literacy was positively associated with high PCC regardless of race and ethnicity.

Parental Perceptions of Access to and Utilization of Services for Autistic Children in African American Families: An Exploratory Study

Autism spectrum disorder (ASD) occurs within all racial, ethnic, and demographic pediatric groups. However, Black children with ASD are diagnosed at later stages of their development, and as a result may not receive or may age out of early intervention services, and demonstrate poorer long-term outcomes, across a range of factors. African American parent's perceptions regarding access to and utilization of healthcare services for their autistic children vary. Research examining autism spectrum disorder and parental perceptions of service utilization among African American (AA) families is limited. This qualitative study aimed to understand the challenges African American parents face when initiating healthcare services for their autistic children. Eleven AA mothers of autistic children participated in individual semi-structured interviews. Six themes related to pediatric treatment needs, interactions with providers, and parents' roles as experts and advocates were generated. Implications for pediatric treatment needs of autistic children and areas of opportunity for providers working with AA autistic children are discussed.

Trends and Disparities in Newer GLP1 Receptor Agonist Initiation among Real-World Adult Patients Eligible for Obesity Treatment

Aims

To characterize trends in the initiation of newer anti-obesity medications (AOMs) and determine factors associated with their use among obese/overweight populations.

Materials and methods

This retrospective study utilized electronic health record data from OneFlorida+ (2015-2024). Adults eligible for AOMs were included, defined as having a BMI ≥30 kg/m² or a BMI of 27-29.9 kg/m² with at least one obesity-related comorbidity. The primary outcome was the initiation of newer AOMs, specifically glucagon-like peptide-1 receptor agonists (GLP-1 RAs) including liraglutide, semaglutide, and tirzepatide. Trends across years were examined, and a multivariable logistic regression identified sociodemographic, clinical, and healthcare utilization factors associated with AOM initiation.

Results

Of 319,949 adults, 1.8% initiated newer AOMs. Semaglutide accounted for 77.9% of initiations, tirzepatide 19.7%, and liraglutide 17.8%. Initiation trends showed liraglutide uptake peaked at 5% in 2018 but declined afterward, while semaglutide and tirzepatide uptake increased exponentially since 2022. Odds of initiation were lower for Black (aOR (95% CI): 0.87 [0.80- 0.94]) and Hispanic (0.84 [0.78-0.91]) groups vs. Whites, and for Medicaid (0.69 [0.63-0.76]) and uninsured (0.81 [0.74-0.87]) patients vs. privately insured. Higher odds were associated with being female, middle-aged, having more outpatient visits, and visiting endocrinologists.

Conclusions

The initiation of newer AOMs among overweight and obese populations remains low, but uptake has increased exponentially since 2022. Our findings reveal significant disparities in obesity care, highlighting the importance of addressing inequities in AOM access to improve obesity outcomes.

The Invisibility of the Multiply Stigmatized Patient: Intersections of Ethnic Prejudice and Stigma of Chronic Disease in Medical Students

Ethnic prejudice in healthcare has been widely examined, yet little is known about its intersection with stigma and prejudice based on one's health status. The present study investigates the intersections of ethnic prejudice and stigma of chronic disease in a healthcare setting as shaping unique forms of disadvantage. From an intersectional perspective, we examined whether ethnically diverse patients affected by stigmatized health conditions would be differentially perceived and cared for by prospective medical doctors. In a within-subjects, experimental design, preclinical medical students read, and evaluated clinical vignettes describing patients, who were presented as either White Italian or Middle Eastern migrants and were affected by visible and concealable stigmatized chronic conditions. Emotional reactions, attributions about disease-onset, caretaking attitudes, and meta-beliefs about patient disclosure behavior were assessed. Results showed that when reading of patients affected by visible compared to concealable stigmatized conditions medical students experienced stigma-related emotions (e.g., disgust, pity, fear) and attributed patients a higher tendency to be embarrassed, to hide, and to avoid disclosure for fear of others' negative reactions. However, Middle Eastern migrants when affected by conditions with visible and behavioral manifestations were attributed a lesser tendency to feel embarrassed, to hide, and to avoid illness disclosure for fear of others' negative reactions compared to White Italian patients with the same conditions. These findings indicate that at the intersection of ethnic prejudice and health-related stigma, multiply stigmatized patients may become invisible and not fully considered in the eyes of medical students. Present results underscore the need to enhance diversity representation in higher medical education for a more inclusive healthcare curriculum and practice.

"Racism Happens Every Day, All the Time": Black Families' Outpatient Experiences of Racism Across a Large Pediatric System

OBJECTIVE

To qualitatively understand and characterize the experience of racism in outpatient pediatric healthcare settings from the perspectives of Black families.

METHODS

We conducted focus groups with parents or guardians of Black children, recruited from academic primary care offices at a single pediatric institution. Focus groups were facilitated virtually by Black team members using an open-ended, semi-structured focus group guide. We analyzed focus group transcripts using iterative, thematic, inductive open coding performed independently by trained coders, with final codes reached by group consensus.

RESULTS

We conducted 6 focus groups of 3 to 5 participants each and 1 individual interview, with 24 total parents. We identified the following themes: 1) "I just felt like we was a number": Black families perceived experiences that felt impersonal and lacked empathy; 2) "Why is the doctor treating me like I don't matter?": Black families perceived experiences with poor care and worse treatment; 3) Black families experience racism across socioecological levels when interacting with pediatric health systems; 4) Positive perceived experiences can guide improvement; and 5) Improvement will require antiracist efforts across the levels of racism.

CONCLUSIONS

In this qualitative study, we found that Black families have had many poor pediatric experiences, perceive racism as affecting child health broadly across socioecological levels, and recommend a multidimensional antiracist approach to improvement. Our findings underscore the importance of elevating Black family voices in developing policies that prioritize antiracism and work to eliminate the harmful impacts of racism on child health.

Attitudes Toward Implicit Bias Among Athletic Trainers

Implicit biases are attitudes, emotions, or stereotypes that occur in an unconscious manner and have the potential to negatively affect behaviors, actions, and decisions. Recent studies have suggested that even when certain factors are controlled for, health care workers do not provide equitable care to patients from different demographics. When patients are not receiving equitable health care, there is a potential for disparities in patient-related outcomes. The purpose of this study was to determine attitudes toward implicit bias among athletic trainers. A secondary purpose of this study was to assess differences and correlations between attitudes toward implicit bias and demographic factors including age, years of experience, gender identity, sexual orientation, and race. Participants were recruited for this study by emailing athletic trainers from publicly available staff directories at institutions of higher education and high schools, and athletic training education program directors. The survey consisted of questions gathering demographic information and questions taken from the Attitudes Toward Implicit Bias Instrument. A total of 218 athletic trainers (age = 38 [11] y, years of certified experience = 14 [11] y) opened and completed the survey. On average, participants scored 71.0 [11.2] on the Attitudes Toward Implicit Bias Instrument. This mean score indicated that the average participant felt that implicit bias had the potential to negatively impact patient care and needed to be addressed through education. There was a significant, negligible negative correlation between age and attitudes toward implicit bias (r[216] = -.157, P = .02). Examining implicit bias among athletic trainers warrants further research to understand how implicit bias can negatively affect access to equitable health care opportunities. The development of high-quality interventions for identifying and addressing implicit bias is crucial to ensuring optimal patient outcomes in athletic training and all medical settings.

Healthcare providers' psychological investment in clinical recommendations: Investigating the role of implicit racial attitudes

Racial disparities in clinical recommendations can result in racial disparities in health. While healthcare providers' implicit racial attitudes (affective component of bias) are theorized to be one major factor contributing to racial disparities in clinical recommendations, empirical evidence to support the link is lacking. This study aimed to bridge this gap by moving beyond the standard approach of operationalizing the quality of clinical recommendations as a guideline-consistent vs. -inconsistent dichotomy. The present secondary study examined the role of provider implicit racial attitudes in the quality of clinical recommendations, operationalized as behaviors reflecting providers' psychological investment in patient care (i.e., number of words used to describe clinical recommendations, and number of treatment options recommended). Two-hundred-and-ten White medical trainees reviewed a clinical vignette of either a White or Black male patient and provided clinical recommendations. Their implicit racial attitudes were evaluated using the Implicit Association Test. Participants with more biased implicit racial attitudes (i.e., stronger implicit preference for White vs. Black individuals) used fewer words to describe their clinical recommendations and provided fewer clinical recommendations for the Black (vs. White) patient, while there were no significant differences between Black and White patients among participants with less biased implicit racial attitudes. These results illustrate the insidious impact of implicit racial attitudes in healthcare provision and underscore the need for researchers to consider the complex, nuanced ways in which provider implicit racial attitudes might manifest in clinical decision-making.

Empathic Communication and Implicit Bias in the Context of Cancer Among a Medical Student Sample

Oncology clinicians often miss opportunities to communicate empathy to patients. The current study examined the relationship between implicit bias (based on cancer type and ethnicity) and medical students' empathic communication in encounters with standardized patients who presented as Hispanic (lung or colorectal) individuals diagnosed with cancer. Participants (101 medical students) completed the Implicit Association Test (IAT) to measure implicit bias based on cancer type (lung v. colorectal) and ethnicity (Hispanic v. non-Hispanic White). Empathic opportunities and responses (assessed by the Empathic Communication Coding System; ECCS) were evaluated in a mock consultation (Objective Structured Clinical Examination; OSCE) focused on smoking cessation in the context of cancer. Among the 241 empathic opportunities identified across the 101 encounters (M = 2.4), 158 (65.6%) received high empathy responses from the medical students. High empathy responses were most frequently used during challenge (73.2%) and emotion (77.3%) opportunities compared to progress (45.9%) opportunities. Higher levels of implicit bias against Hispanics predicted lower odds of an empathic response from the medical student (OR = 3.24, p = .04, 95% CI = 0.09-0.95). Further work is needed to understand the relationship between implicit bias and empathic communication and inform the development of interventions.

Assessing Bias Toward a Black or White Simulated Patient with Obesity in a Virtual Reality-Based Genomics Encounter

Interpersonal bias based on weight and race is widespread in the clinical setting; it is crucial to investigate how emerging genomics technologies will interact with and influence such biases in the future. The current study uses a virtual reality (VR) simulation to investigate the influence of apparent patient race and provision of genomic information on medical students' implicit and explicit bias toward a virtual patient with obesity. Eighty-four third- and fourth-year medical students (64% female, 42% White) were randomized to interact with a simulated virtual patient who appeared as Black versus White, and to receive genomic risk information for the patient versus a control report. We assessed biased behavior during the simulated encounter and self-reported attitudes toward the virtual patient. Medical student participants tended to express more negative attitudes toward the White virtual patient than the Black virtual patient (both of whom had obesity) when genomic information was absent from the encounter. When genomic risk information was provided, this more often mitigated bias for the White virtual patient, whereas negative attitudes and bias against the Black virtual patient either remained consistent or increased. These patterns underscore the complexity of intersectional identities in clinical settings. Provision of genomic risk information was enough of a contextual shift to alter attitudes and behavior. This research leverages VR simulation to provide an early look at how emerging genomic technologies may differentially influence bias and stereotyping in clinical encounters.

County-level racial bias is associated with worse care for white and especially black older US adults: a cross-sectional observational study

OBJECTIVE

To assess the association of county-level bias about black and white people with patient experience, influenza immunisation, and quality of clinical care for black and white older US adults (age 65+ years).

DESIGN

Linear multivariable regression measured the cross-sectional association of county-level estimates of implicit and explicit bias about black and white people with patient experiences, influenza immunisation, and clinical quality-of-care for black and white older US adults.

PARTICIPANTS

We used data from 1.9 million white adults who completed implicit and explicit bias measures during 2003-2018, patient experience and influenza immunisation data from respondents to the 2009-2017 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Surveys, and clinical quality-of-care data from patients whose records were included in 2009-2017 Healthcare Effectiveness Data and Information Set (HEDIS) submissions (n=0.8-2.9 million per measure).

MAIN OUTCOME MEASURES

Three patient experience measures and patient-reported influenza immunisation from the MCAHPS Survey; five HEDIS measures.

RESULTS

In county-level models, higher pro-white implicit bias was associated with lower immunisation rates and worse scores for some patient experience measures for black and white adults as well as larger-magnitude black-white disparities. Higher pro-white implicit bias was associated with worse scores for some HEDIS measures for black and white adults but not with black-white disparities in clinical quality of care. Most significant associations were small in magnitude (effect sizes of 0.2-0.3 or less).

CONCLUSIONS

To the extent that county-level pro-white implicit bias is indicative of bias among healthcare providers, there may be a need for interventions designed to prevent such bias from adversely affecting the experiences and preventive care of black patients and the clinical quality of care for all patients.

The prevalence of Black/African American individuals in concussion literature: a systematic review and meta-analysis

Introduction

Comprising approximately 13.6% of the United States population, Black/African American individuals are overrepresented in sports associated with a high risk of concussion. However, there has been a notable absence of systematic reviews examining whether concussion literature accurately reflects the participation and experiences of Black/African American individuals. Therefore, this study aims to systematically review the prevalence of Black/African American individuals compared to White individuals diagnosed with concussions in the literature.

Methods

A systematic search was performed across four electronic databases: PubMed, MEDLINE (Ovid), Scopus and Web of Science. Articles were searched from inception to January 5, 2022. Prevalence data were extracted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A meta-analysis of proportions was conducted within hospital records and national survey data.

Results

Among 447 identified studies, 11 were included, representing 1,839,901 individuals diagnosed with a concussion, with 73.6% identifying as White and 12.5% identifying as Black/African American. The mean proportion of Black/African American diagnosed with a concussion in hospital records (13.9%; 95% CI [12.8, 15.1]) exceeded that in national surveys (6.4%; 95% CI [3.5, 11.3]) but lower than sports-centered studies (16%).

Discussion

These findings underscore the need to address racial disparities in healthcare within the broader context of social determinants of health and systemic inequities. By identifying gaps in the current research, this study lays the foundation for future investigation aimed at elucidating and addressing healthcare disparities.

Beyond the Question: Reexamining a Parent's Unusual Request

Pediatricians sometimes think about medical ethics as the field of determining right and wrong in in answering difficult moral questions that occur at the bedside. But an emphasis on rapidly determining right and wrong when faced with ethical dilemmas can lead clinicians to miss important issues underlying both the question and their approach to answering it. We argue that ethical reflection is not merely a process of getting to the right answer but also a way to probe beyond the original question to better understand the stakeholders' perspectives and priorities. In this Ethics Rounds, we present the case of an infant born at 23 weeks' gestation who initially faced numerous complications of prematurity, but has progressed beyond acute critical illness. His father requests a transition to palliative care at a point this option would not typically be offered. The straightforward response to this father's request is "no." However, we reexamine the father's request from the perspective of a neonatologist, a clinical ethicist, and a conflict mediator. Why is the father making this request? Why do clinicians feel rushed to respond? The authors discuss how elements of surprise and implicit biases can push clinicians to hasty answers. We introduce tools used in clinical ethics consultation and conflict mediation that can facilitate alternative responses from the clinical team. Employing the "Ladder of Inference," ascertaining the "View from Everywhere," and differentiating positions from interests can help clinicians explore the context of ethical questions and lead to more fruitful resolutions.

Racial and Socioeconomic Disparities Evident in Inappropriate Antibiotic Prescribing in the Emergency Department

STUDY OBJECTIVE

Inappropriate antibiotic prescribing for acute respiratory tract infections is a common source of low-value care in the emergency department (ED). Racial and socioeconomic disparities have been noted in episodes of low-value care, particularly in children. We evaluated whether prescribing rates for acute respiratory tract infections when antibiotics would be inappropriate by guidelines differed by race and socioeconomics.

METHODS

A retrospective cross-sectional analysis of adult and pediatric patient encounters in the emergency department (ED) between 2015 and 2023 at 5 hospitals for acute respiratory tract infections that did not require antibiotics by guidelines. Multivariable regression was used to calculate the risk ratio between race, ethnicity, and area deprivation index and inappropriate antibiotic prescribing, controlling for patient age, sex, and relevant comorbidities.

RESULTS

A total of 147,401 ED encounters (55% pediatric, 45% adult) were included. At arrival, 4% patients identified as Asian, 50% as Black, 5% as Hispanic, and 23% as White. Inappropriate prescribing was noted in 7.6% of overall encounters, 8% for Asian patients, 6% for Black patients, 5% for Hispanic patients, and 12% for White patients. After adjusting for age, sex, comorbidities, and area deprivation index, White patients had a 1.32 (95% confidence interval, 1.26 to 1.38) higher likelihood of receiving a prescription compared with Black patients. Patients residing in areas of greater socioeconomic deprivation, regardless of race and ethnicity, had a 0.74 (95% confidence interval, 0.70 to 0.78) lower likelihood of receiving a prescription.

CONCLUSION

Our results suggest that although overall inappropriate prescribing was relatively low, White patients and patients from wealthier areas were more likely to receive an inappropriate antibiotic prescription.

Addressing Disparities in Pediatric Congenital Heart Disease: A Call for Equitable Health Care

While significant progress has been made in reducing disparities within the US health care system, notable gaps remain. This article explores existing disparities within pediatric congenital heart disease care. Congenital heart disease, the most common birth defect and a leading cause of infant death, has garnered substantial attention, revealing certain disparities within the US health care system. Factors such as race, ethnicity, insurance coverage, socioeconomic status, and geographic location are all commonalities that significantly affect health disparities in pediatric congenital heart disease. This comprehensive review sheds light on disparities from diverse perspectives in pediatric care, demonstrates the inequities and inequalities leading to these disparities, presents effective solutions, and issues a call to action for providers, institutions, and the health care system. Recognizing and addressing these disparities is imperative for ensuring equitable care and enhancing the long-term well-being of children affected by congenital heart disease. Implementing robust, evidence-based frameworks that promote responsible and safe interventions is fundamental to enduring change.

Investigating Unconscious Race Bias and Bias Awareness Among Vascular Surgeons

Background

Implicit bias can influence behavior and decision-making. In clinical settings, implicit bias may influence treatment decisions and contribute to health disparities. Given documented Black-White disparities in vascular care, the purpose of this study was to examine the prevalence and degree of unconscious bias and awareness of bias among vascular surgeons treating peripheral artery disease (PAD).

Methods

The sampling frame included all vascular surgeons who participate in the Vascular Quality Initiative (VQI). Participants completed a survey which included demographic questions, the race implicit association test (IAT) to measure magnitude of unconscious bias, and six bias awareness questions to measure conscious bias. The magnitude of unconscious bias was no preference; or slight, moderate, or strong in the direction of pro-White or pro-Black. Data from participants were weighted to account for nonresponse bias and known differences in the characteristics of surgeons who chose to participate compared to the full registry. We stratified unconscious and conscious findings by physician race/ethnicity, physician sex, and years of experience. Finally, we examined the relationship between unconscious and conscious bias.

Results

There were 2,512 surgeons in the VQI registry, 304 of whom completed the survey, including getting IAT results. Most participants (71.6%) showed a pro-White bias with 73.0% of this group in the moderate and strong categories. While 77.5% of respondents showed conscious awareness of bias, of those whose conscious results showed lack of awareness, 67.8% had moderate or strong bias, compared to 55.7% for those with awareness. Bias magnitude varied based on physician race/ethnicity and years of experience. Women were more likely than men to report awareness of biases and potential impact of bias on decision-making.

Conclusions

Most people have some level of unconscious bias, developed from early life reinforcements, social stereotypes, and learned experiences. Regarding health disparities, however, these are important findings in a profession that takes care of patients with PAD due to heavy burden of comorbid conditions and high proportion of individuals from structurally vulnerable groups. Given the lack of association between unconscious and conscious awareness of biases, awareness may be an important first step in mitigation to minimize racial disparities in healthcare.

Experiences and Challenges of African American and Sub-Saharan African Immigrant Black Women in Completing Pap Screening: a Mixed Methods Study

BACKGROUND

Understanding Black women's Papanicolaou (Pap) screening experiences can inform efforts to reduce cancer disparities. This study examined experiences among both US-born US Black women and Sub-Saharan African immigrant women.

METHOD

Using a convergent parallel mixed methods design, Black women born in the USA and in Sub-Saharan Africa age 21-65 years were recruited to participate in focus groups and complete a 25-item survey about patient-centered communication and perceived racial discrimination. Qualitative and quantitative data were integrated to provide a fuller understanding of results.

RESULTS

Of the 37 participants, 14 were US-born and 23 were Sub-Saharan African-born Black women. The mean age was 40.0 ± 11.0, and 83.8% had received at least one Pap test. Five themes regarding factors that impact screening uptake emerged from the focus groups: (1) positive and negative experiences with providers; (2) provider communication and interaction; (3) individual barriers to screening uptake, (4) implicit bias, discrimination, and stereotypical views among providers, and (5) language barrier. Survey and focus group findings diverged on several points. While focus group themes captured both positive and negative experiences with provider communication, survey results indicated that most of both US-born and Sub-Saharan African-born women experienced positive patient-centered communication with health care providers. Additionally, during focus group sessions many participants described experiences of discrimination in health care settings, but less than a third reported this in the survey.

CONCLUSION

Black women's health care experiences affect Pap screening uptake. Poor communication and perceived discrimination during health care encounters highlight areas for needed service improvement to reduce cervical cancer disparities.

Racial and Ethnic Disparities in Cardiac Reintervention After Pediatric Cardiac Surgical Procedures

BACKGROUND

Children undergoing cardiac surgical procedures may require postoperative surgical or catheter-based reintervention before discharge. We examined racial/ethnic variations in reintervention and associated in-hospital death.

METHODS

Children undergoing cardiac surgical procedures from 2004 to 2015 were identified in the Pediatric Health Information Systems (PHIS) database. Regression analysis measured associations between race/ethnicity, in-hospital death, and postoperative cardiac surgical or catheter-based reintervention (surgical/catheter reintervention).

RESULTS

Of 124,263 patients, 8265 (6.7%) had a surgical/catheter reintervention. Black patients had fewer reinterventions (5.9% vs 6.7%) and higher in-hospital mortality (3.9% vs 2.7%, P < .01) than White patients. After adjusting for sociodemographic and illness severity indicators, Black patients remained less likely to receive surgical/catheter reintervention (adjusted hazard ratio [aHR], 0.89; 95% CI, 0.82-0.98) despite having similar risk of death after reintervention (adjusted odds ratio, 1.17; 95% CI, 0.98-1.41) compared with White patients. The risk of death without surgical/catheter reintervention was also higher for Black (aHR, 1.26; 95% CI, 1.08-1.47) and other race/ethnicity (aHR, 1.33; 95% CI, 1.13-1.57) patients than for White patients. Similar trends were demonstrated when mechanical circulatory support and cardiac transplantation were included as reinterventions.

CONCLUSIONS

Patients of Black and other race/ethnicity undergoing pediatric cardiac surgical procedures are more likely to die without postoperative cardiac reintervention than White patients. Black patients are also less likely to receive reintervention despite no significant difference in mortality with reintervention. Further studies should evaluate etiologies and methods of addressing these disparities.

Examining Linguistic Differences in Electronic Health Records for Diverse Patients With Diabetes: Natural Language Processing Analysis

Background

Individuals from minoritized racial and ethnic backgrounds experience pernicious and pervasive health disparities that have emerged, in part, from clinician bias.

Objective

We used a natural language processing approach to examine whether linguistic markers in electronic health record (EHR) notes differ based on the race and ethnicity of the patient. To validate this methodological approach, we also assessed the extent to which clinicians perceive linguistic markers to be indicative of bias.

Methods

In this cross-sectional study, we extracted EHR notes for patients who were aged 18 years or older; had more than 5 years of diabetes diagnosis codes; and received care between 2006 and 2014 from family physicians, general internists, or endocrinologists practicing in an urban, academic network of clinics. The race and ethnicity of patients were defined as White non-Hispanic, Black non-Hispanic, or Hispanic or Latino. We hypothesized that Sentiment Analysis and Social Cognition Engine (SEANCE) components (ie, negative adjectives, positive adjectives, joy words, fear and disgust words, politics words, respect words, trust verbs, and well-being words) and mean word count would be indicators of bias if racial differences emerged. We performed linear mixed effects analyses to examine the relationship between the outcomes of interest (the SEANCE components and word count) and patient race and ethnicity, controlling for patient age. To validate this approach, we asked clinicians to indicate the extent to which they thought variation in the use of SEANCE language domains for different racial and ethnic groups was reflective of bias in EHR notes.

Results

We examined EHR notes (n=12,905) of Black non-Hispanic, White non-Hispanic, and Hispanic or Latino patients (n=1562), who were seen by 281 physicians. A total of 27 clinicians participated in the validation study. In terms of bias, participants rated negative adjectives as 8.63 (SD 2.06), fear and disgust words as 8.11 (SD 2.15), and positive adjectives as 7.93 (SD 2.46) on a scale of 1 to 10, with 10 being extremely indicative of bias. Notes for Black non-Hispanic patients contained significantly more negative adjectives (coefficient 0.07, SE 0.02) and significantly more fear and disgust words (coefficient 0.007, SE 0.002) than those for White non-Hispanic patients. The notes for Hispanic or Latino patients included significantly fewer positive adjectives (coefficient -0.02, SE 0.007), trust verbs (coefficient -0.009, SE 0.004), and joy words (coefficient -0.03, SE 0.01) than those for White non-Hispanic patients.

Conclusions

This approach may enable physicians and researchers to identify and mitigate bias in medical interactions, with the goal of reducing health disparities stemming from bias.

Association of patient characteristics and insurance type with anti-obesity medications prescribing and fills

AIM

To characterize factors associated with the receipt of anti-obesity medication (AOM) prescription and fill.

MATERIALS AND METHODS

This retrospective cohort study used electronic health records from 1 January 2015 to 30 June 2023, in a large health system in Ohio and Florida. Adults with a body mass index ≥30 kg/m2 who attended ≥1 weight-management programme or had an initial AOM prescription between 1 July 2015 and 31 December 2022, were included. The main measures were a prescription for an AOM (naltrexone-bupropion, orlistat, phentermine-topiramate, liraglutide 3.0 mg and semaglutide 2.4 mg) and an AOM fill during the study follow-up.

RESULTS

We identified 50 678 adults, with a mean body mass index of 38 ± 8 kg/m2 and follow-up of 4.7 ± 2.4 years. Only 8.0% of the cohort had AOM prescriptions and 4.4% had filled prescriptions. In the multivariable analyses, being a man, Black, Hispanic and other race/ethnicity (vs. White), Medicaid, traditional Medicare, Medicare Advantage, self-pay and other insurance types (vs. private insurance) and fourth quartile of the area deprivation index (vs. first quartile) were associated with lower odds of a new prescription. Hispanic ethnicity, being a man, Medicaid, traditional Medicare and Medicare Advantage insurance types, liraglutide and orlistat (vs. naltrexone-buproprion) were associated with lower odds of AOM fill, while phentermine-topiramate was associated with higher odds. Among privately insured individuals, the insurance carrier was associated with both the odds of AOM prescription and fill.

CONCLUSIONS

Significant disparities exist in access to AOM both at the prescribing stage and getting the prescription filled based on patient characteristics and insurance type.

Intercultural effectiveness in GPs' communication and clinical assessment: An experimental study

OBJECTIVE

This study aimed to investigate potential disparities in general practitioners' overall communication and clinical assessments based on patient ethnicity, while examining the influence of intercultural effectiveness.

METHODS

Employing a 2 × 2 experimental study design, online video recorded consultations with simulated patients were conducted and analyzed using OSCEs. Each GP (N = 100) completed a consultation with both an ethnic majority and an ethnic minority patient. Additionally, a follow-up survey was administered to gather supplementary data. Paired sample t-tests explored ethnic disparities, correlation and regression analyses determined associations with intercultural attitudes, traits and capabilities.

RESULTS

No statistically significant differences in GPs' communication or clinical assessment were found based on patients' ethnic background. Positive associations were observed between all aspects of intercultural effectiveness and GPs' consultation behavior. Intercultural traits emerged as a strong and robust predictor of clinical assessment of ethnic minority patients.

CONCLUSION

Intercultural traits, such as ethnocultural empathy, may play a critical role in GPs' clinical assessment skills during intercultural consultations.

PRACTICE IMPLICATIONS

Findings provide valuable insights into the determinants of intercultural effectiveness in healthcare, fostering promising targets for interventions and training programs aiming to ensure higher-quality and more equitable care delivery.

Are Safety-Net Primary Care Physicians Prepared to Engage in Serious Illness Conversations?

BACKGROUND

Advance Care Planning (ACP) has not reliably improved care for patients at end-of-life. Serious Illness Conversations when patients are in the late stages of chronic illness might be more effective to address patients' goals. The Serious Illness Conversation (SIC) Guide has been helpful but was not developed for use in safety-net settings serving racial and ethnic minority populations.

METHODS

Physicians were recruited to complete a needs assessment survey prior to training in the use of the SIC Guide.

RESULTS

Of the 44 physician participants, most were female (82%) and white, non-Hispanic (62%). Less than half of respondents rated themselves as skilled or very skilled in basic serious illness communication related tasks such as setting up goals of care discussions (44%), assessing informational preferences (42%), sharing prognosis (38%), exploring goals for future care (49%) and managing family dynamics (44%). Respondents reported lower skill levels in conducting goals of care conversations via telehealth and establishing trust in racially discordant provider/patient pairs.

CONCLUSIONS

Most participants expressed the need for further training in critical end-of-life communications skills, including help with encounters with racial and/or language discordance. This may help to explain the failure of ACP discussions to reliably result in appropriate end-of-life care.

Estimating implicit and explicit racial and ethnic bias among community pharmacists in Canada

Background

Bias, whether implicit (unconscious) or explicit (conscious), can lead to preferential treatment of specific social groups and antipathy towards others. When healthcare professionals (HCPs), including pharmacists, act on these biases, patient care and health outcomes can be adversely affected. This study aims to estimate implicit and explicit racial/ethnic bias towards Black and Arab people among community pharmacists in Ontario, Canada.

Methods

Community pharmacists participated in a secure, web-based survey using a cross-sectional design that included Harvard's Race and Arab Implicit Association Tests (IATs) to examine bias towards Black and Arab people. Explicit (stated) preferences were measured by self-report. Data were analyzed using descriptive and inferential statistics.

Results

The study surveyed 407 community pharmacists, 56.1 % of whom were women with an average age of 46.9. Implicit Association Test (IAT) results showed a statistically significant moderate preference for white people over both Black (mean IAT = 0.41) and Arab people (mean IAT = 0.35). However, most pharmacists explicitly stated that they had no racial/ethnic preference, with 75.7 % expressing a neutral preference between Black and white and 66.6 % neutral between Arab and white. However, a slight preference for white individuals was observed. Demographic factors such as age, place of birth, race/ethnicity, and experience significantly impacted IAT scores. For example, older, Canadian-born, white pharmacists with more experience displayed higher implicit bias scores. A mild correlation was found between implicit and explicit bias, indicating as implicit bias increases, explicit bias tends to become more negative.

Conclusions

This study is the first to explore the issue of pharmacist bias in Canada and concentrate on anti-Arab bias. Our findings reveal that Ontario community pharmacists tend to have an unconscious inclination towards white people, which calls for further understanding of this matter. Additionally, we discovered a moderate degree of anti-Arab bias, indicating that studies on other HCPs should consider bias against this social group. Educational interventions are needed to address the implicit biases among community pharmacists in Ontario, Canada. These findings should aim to raise self-awareness of biases, educate about the potential implications of these biases on patient care, and provide strategies to reduce bias.

Understanding Symptom Self-Monitoring Needs Among Postpartum Black Patients: Qualitative Interview Study

BACKGROUND

Pregnancy-related death is on the rise in the United States, and there are significant disparities in outcomes for Black patients. Most solutions that address pregnancy-related death are hospital based, which rely on patients recognizing symptoms and seeking care from a health system, an area where many Black patients have reported experiencing bias. There is a need for patient-centered solutions that support and encourage postpartum people to seek care for severe symptoms.

OBJECTIVE

We aimed to determine the design needs for a mobile health (mHealth) patient-reported outcomes and decision-support system to assist Black patients in assessing when to seek medical care for severe postpartum symptoms. These findings may also support different perinatal populations and minoritized groups in other clinical settings.

METHODS

We conducted semistructured interviews with 36 participants-15 (42%) obstetric health professionals, 10 (28%) mental health professionals, and 11 (31%) postpartum Black patients. The interview questions included the following: current practices for symptom monitoring, barriers to and facilitators of effective monitoring, and design requirements for an mHealth system that supports monitoring for severe symptoms. Interviews were audio recorded and transcribed. We analyzed transcripts using directed content analysis and the constant comparative process. We adopted a thematic analysis approach, eliciting themes deductively using conceptual frameworks from health behavior and human information processing, while also allowing new themes to inductively arise from the data. Our team involved multiple coders to promote reliability through a consensus process.

RESULTS

Our findings revealed considerations related to relevant symptom inputs for postpartum support, the drivers that may affect symptom processing, and the design needs for symptom self-monitoring and patient decision-support interventions. First, participants viewed both somatic and psychological symptom inputs as important to capture. Second, self-perception; previous experience; sociocultural, financial, environmental, and health systems-level factors were all perceived to impact how patients processed, made decisions about, and acted upon their symptoms. Third, participants provided recommendations for system design that involved allowing for user control and freedom. They also stressed the importance of careful wording of decision-support messages, such that messages that recommend them to seek care convey urgency but do not provoke anxiety. Alternatively, messages that recommend they may not need care should make the patient feel heard and reassured.

CONCLUSIONS

Future solutions for postpartum symptom monitoring should include both somatic and psychological symptoms, which may require combining existing measures to elicit symptoms in a nuanced manner. Solutions should allow for varied, safe interactions to suit individual needs. While mHealth or other apps may not be able to address all the social or financial needs of a person, they may at least provide information, so that patients can easily access other supportive resources.

Storylines of family medicine X: standing up for diversity, equity and inclusion

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'X: standing up for diversity, equity and inclusion', authors address the following themes: 'The power of diversity-why inclusivity is essential to equity in healthcare', 'Medical education for whom?', 'Growing a diverse and inclusive workforce', 'Therapeutic judo-an inclusive approach to patient care', 'Global family medicine-seeing the world "upside down"', 'The inverse care law', 'Social determinants of health as a lens for care', 'Why family physicians should care about human rights' and 'Toward health equity-the opportunome'. May the essays that follow inspire readers to promote change.

Moving toward Narrowing the United States Gap in Assisted Reproductive Technology (ART) Racial and Ethnic Disparities in the Next Decade

The Disparities in Assisted Reproductive Technology (DART) hypothesis, initially described in 2013 and further modified in 2022, is a conceptual framework to examine the scope and depth of underlying contributing factors to the differences in access and treatment outcomes for racial and ethnic minorities undergoing ART in the United States. In 2009, the World Health Organization defined infertility as a disease of the reproductive system, thus recognizing it as a medical problem warranting treatment. Now, infertility care is largely recognized as a human right. However, disparities in Reproductive Endocrinology and Infertility (REI) care in the US persist today. While several studies and review articles have suggested possible solutions to racial and ethnic disparities in access and outcomes in ART, few have accounted for and addressed the multiple complex factors contributing to these disparities on a systemic level. This review aims to acknowledge and address the myriad of contributing factors through the DART hypothesis which converge in racial/ethnic disparities in ART and considers possible solutions to effect large scale societal change by narrowing these gaps within the next decade.

Racial Implicit Bias and Communication Among Physicians in a Simulated Environment

Importance

Racial implicit bias can contribute to health disparities through its negative influence on physician communication with Black patients. Interventions for physicians to address racial implicit bias in their clinical encounters are limited by a lack of high-fidelity (realistic) simulations to provide opportunities for skill development and practice.

Objective

To describe the development and initial evaluation of a high-fidelity simulation of conditions under which physicians might be influenced by implicit racial bias.

Design, Setting, and Participants

This cross-sectional study, performed on an online platform from March 1 to September 30, 2022, recruited a convenience sample of physician volunteers to pilot an educational simulation.

Exposures

In the simulation exercise, physicians saw a 52-year-old male standardized patient (SP) (presenting as Black or White) seeking urgent care for epigastric pain, nausea, and vomiting. The case included cognitive stressors common to clinical environments, including clinical ambiguity, stress, time constraints, and interruptions. Physicians explained their diagnosis and treatment plan to the SP, wrote an assessment and management plan, completed surveys, and took the Race Implicit Association Test (IAT) and Race Medical Cooperativeness IAT. The SPs, blinded to the purpose of the study, assessed each physician's communication using skills checklists and global rating scales.

Main Outcomes and Measures

Association between physicians' IAT scores and SP race with SP ratings of communication skills.

Results

In 60 physicians (23 [38.3%] Asian, 4 [6.7%] Black, 23 [38.3%] White, and 10 [16.7%] other, including Latina/o/x, Middle Eastern, and multiracial; 31 [51.7%] female, 27 [45.0%] male, and 2 [3.3%] other), the interaction of physicians' Race IAT score and SP race was significant for overall communication (mean [SD] β = -1.29 [0.41]), all subdomains of communication (mean [SD] β = -1.17 [0.52] to -1.43 [0.59]), and overall global ratings (mean [SD] β = -1.09 [0.39]). Black SPs rated physicians lower on communication skills for a given pro-White Race IAT score than White SPs; White SP ratings increased as physicians' pro-White bias increased.

Conclusions and Relevance

In this cross-sectional study, a high-fidelity simulation calibrated with cognitive stressors common to clinical environments elicited the expected influence of racial implicit bias on physicians' communication skills. The outlined process and preliminary results can inform the development and evaluation of interventions that seek to address racial implicit bias in clinical encounters and improve physician communication with Black patients.

Sexual Orientation and Racial Bias in Relation to Medical Specialty

Physician explicit and implicit biases involving race and sexual orientation (SO) affect patient and provider experiences in healthcare settings. An anonymous survey was disseminated nationally to graduating medical students, residents, and practicing physicians to evaluate SO and racial biases across medical specialties. SO explicit and implicit bias were measured with the Attitudes toward Lesbians and Gay Men Scale, short form (ATLG-S) and Gay-Straight Implicit Association Test (IAT). Racial explicit and implicit bias were measured with the Quick Discrimination Index (QDI) and the Black-White IAT. Medical specialty was associated with racial explicit bias and specialty prestige with Black-White IAT score. Medical specialty and specialty prestige were not associated with SO bias. Female sex, sexual and gender minority (SGM) identity, and decreased religiosity were associated with reduced SO and racial bias. Provider race was associated with racial implicit and explicit bias.

Examining the pedagogical practices that support cultural proficiency development in graduate health science students

BACKGROUND

Health disparities are often a function of systemic discrimination and healthcare providers' biases. In recognition of this, health science programs have begun to offer training to foster cultural proficiency (CP) in future professionals. However, there is not yet consensus about the best ways to integrate CP into didactic and clinical education, and little is known about the role of clinical rotations in fostering CP.

METHODS

Here, a mixed-methods approach was used to survey students (n = 131) from a private all-graduate level osteopathic health sciences university to gain insight into the training approaches students encountered related to CP and how these may vary as a function of academic progression. The research survey included instruments designed to quantify students' implicit associations, beliefs, and experiences related to the CP training they encountered through the use of validated instruments, including Implicit Association Tests and the Ethnocultural Empathy Inventory, and custom-designed questions.

RESULTS

The data revealed that most students (73%) had received CP training during graduate school which primarily occurred via discussions, lectures, and readings; however, the duration and students' perception of the training varied substantially (e.g., training range = 1-100 hours). In addition, while students largely indicated that they valued CP and sought to provide empathetic care to their patients, they also expressed personal understandings of CP that often fell short of advocacy and addressing personal and societal biases. The results further suggested that clinical rotations may help students attenuate implicit biases but did not appear to be synergistic with pre-clinical courses in fostering other CP knowledge, skills, and attitudes.

CONCLUSIONS

These findings highlight the need to utilize evidence-based pedagogical practices to design intentional, integrated, and holistic CP training throughout health science programs that employ an intersectional lens and empowers learners to serve as advocates for their patients and address systemic challenges.

Feasibility and acceptability of an online parenting intervention to address behaviour problems in moderately to extremely preterm pre-school and school-age children

BACKGROUND

Preterm birth is associated with adverse mental health outcomes, including internalizing problems, social difficulties and inattention. Interventions are needed beyond infancy and toddlerhood to support children and their families. We examined the feasibility and acceptability of the I-InTERACT Preterm pilot study, an online parenting intervention for preterm children ages 3-8.

METHOD

Families participated in a weekly intervention comprised of seven sessions with online modules followed by videoconference coaching sessions with a therapist. Following completion of the study, caregivers completed a survey to assess their satisfaction and were asked to participate in a voluntary semi-structured interview to provide feedback. We anticipated greater than a 50% participation rate (enrollment feasibility) and 75% completion rate (adherence feasibility). We also hypothesized that at least 80% of participants would be satisfied with the intervention (acceptability).

RESULTS

Nineteen of 32 families (59%) enrolled in the study, suggesting adequate enrollment feasibility. Feasibility of programme completion (adherence) was lower than anticipated (59%). Regarding satisfaction, all caregivers agreed that the programme's information was relevant to them and their family. Nearly all participants (92%) indicated that they had a better understanding of the effects of preterm birth on behaviour, that they enjoyed the programme, that it met their expectations and that they recommend the programme to others. In qualitative interviews, caregivers expressed satisfaction with the content, skills they learned, and receiving direct coaching. Caregivers suggested improvements to increase intervention feasibility and skill implementation, including offering biweekly sessions and more hands-on coaching.

CONCLUSION

Our largely satisfactory acceptability rates suggest the value of and need for a parenting intervention for children born preterm past the initial period of early development. Future directions include modifying the intervention in response to caregiver feedback to improve recruitment, engagement and adherence.

Problematic Integration: Racial Discordance in End-of-Life Decision Making

We describe racially discordant oncology encounters involving EOL decision-making. Fifty-eight provider interviews were content analyzed using the tenets of problematic integration theory. We found EOL discussions between non-Black providers and their Black patients were often complex and anxiety-inducing. That anxiety consisted of (1) ontological uncertainty in which providers characterized the nature of Black patients as distrustful, especially in the context of clinical trials; (2) ontological and epistemological uncertainty in which provider intercultural incompetency and perceived lack of patient health literacy were normalized and intertwined with provider assumptions about patients' religion and support systems; (3) epistemological uncertainty as ambivalence in which providers' feelings conflicted when deciding whether to speak with family members they perceived as lacking health literacy; (4) divergence in which the provider advised palliative care while the family desired surgery or cancer-directed medical treatment; and (5) impossibility when an ontological uncertainty stance of Black distrust was seen as natural by providers and therefore impossible to change. Some communication strategies used were indirect stereotyping, negotiating, asking a series of value questions, blame-guilt framing, and avoidance. We concluded that provider perceptions of Black distrust, religion, and social support influenced their ability to communicate effectively with patients.

Older Adult Frequent 9-1-1 Callers for Emergency Medical Services in a Large Metropolitan City: Individual- and System-Level Considerations

BACKGROUND

High utilizers of 9-1-1 place a substantial burden on emergency medical services (EMS). Results of a retrospective review of records data of the City of Los Angeles Fire Department (LAFD) showed a significant increase in older adult high utilizers of 9-1-1.

OBJECTIVE

The objective of this study was to explore individual- and system-level factors implicated in EMS use among older adults, and to provide system recommendations to mitigate overuse.

METHODS

A phenomenological study was conducted, drawing from LAFD EMS records between 2012 and 2016 to identify and contact high-utilizing patients older than 50 years, their family, agency representatives, and LAFD personnel. Interviews were recorded, transcribed, and coded and a thematic analysis was completed.

RESULTS

We conducted in-depth interviews with 27 participants, including patients (n = 8), their families (n = 6), social service agency representatives (n = 3), and LAFD personnel (n = 10). The following cross-cutting themes emerged: nature of 9-1-1 calls, barriers to access, and changing the system. In addition, LAFD and social service agency representatives identified the role of EMS responders and social agency representatives. Patients and their families agreed that previous encounters and interactions with emergency care responders were relevant factors.

CONCLUSIONS

This study described reasons for 9-1-1 calls related to medical and social service needs, including mental health care. Our analysis offers insight from different stakeholders' perspectives on access to medical care and types of barriers that interfere with medical care. All groups shared recommendations to advance access to medical and mental health care.

Racial and ethnic disparities in the usage and outcomes of ischemic stroke treatment in the United States

OBJECTIVES

This study explores racial and ethnic differences in 1) receiving tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT) as treatment for ischemic stroke and 2) outcomes and quality of care after use of tPA or EVT in the US.

MATERIALS AND METHODS

An observational analysis of 89,035 ischemic stroke patients from the 2019 National Inpatient Sample was conducted. We performed weighted logistic regressions between race and ethnicity and 1) tPA and EVT utilization and 2) in-hospital mortality. We also performed a weighted Poisson regression between race and ethnicity and length of stay (LOS) after tPA or EVT.

RESULTS

Non-Hispanic (NH) Black patients had significantly lower odds of receiving tPA (Adjusted odds ratio [AOR] = 0.85, 95 % Confidence Internal [C.I.]: 0.80-0.91) and EVT (AOR = 0.75, 95 % CI: 0.70-0.82) than NH White patients. Minority populations (including but not limited to NH Black, Hispanic, Pacific Islander, Native American, and Asian) had significantly longer hospital LOS after treatment with tPA or EVT. We did not find a significant difference between race/ethnicity and in-hospital mortality post-tPA or EVT.

CONCLUSIONS

While we failed to find a difference in in-hospital mortality, racial and ethnic disparities are still evident in the decreased usage of tPA and EVT and longer LOSs for racial and ethnic minority patients. This study calls for interventions to expand the utilization of tPA and EVT and advance quality of care post-tPA or EVT in order to improve stroke care for minority patients.

How Subjective and Objective Factors in Research and Practice May Perpetuate Health Disparities Among Patients With Traumatic Brain Injury

ABSTRACT

Research shows disparities exist in traumatic brain injury (TBI)-related outcomes and are associated with objective and subjective factors. Objective factors (e.g., age, sex, race/ethnicity, health insurance status, and socioeconomic status) are defined as variables that are frequently measured, not easily modifiable, and not easily influenced by individual perceptions, opinions, or experiences. Conversely, subjective factors (e.g., personal health literacy, cultural competence, patient/family-clinician communication, implicit bias, and trust) are defined as variables that may be less frequently measured, more easily modifiable, and more easily influenced by individual perceptions, opinions, or experiences. The purpose of this analysis and perspective is to provide recommendations for further examination of subjective factors within TBI research and practice, with the overarching goal of reducing TBI-related disparities. Establishing reliable and valid measures of subjective factors is recommended to allow for further examination of the influence of both objective factors and subjective factors in the TBI population. Providers and researchers must also engage in education and training to recognize their biases and how bias influences decision making. The influence of subjective factors in practice and research must also be considered to ensure that knowledge needed to advance health equity is generated and disparities in outcomes for patients with TBI are reduced.

Inpatient Screening of Parental Adversity and Strengths

BACKGROUND AND OBJECTIVES

Social adversities, including health-harming social risks and adverse childhood experiences, contribute to poor outcomes after hospital discharge. Screening for social adversities is increasingly pursued in outpatient settings. Identifying and addressing such adversities has been linked to improved child outcomes. Screening for social adversities and strengths in the inpatient setting may contribute to better transitions from hospital to home. Our goal was twofold: 1. to use qualitative methods to understand parent perspectives around screening tools for potential use in inpatient settings; and 2. to develop a family-friendly inpatient screening tool for social adversity.

METHODS

We used in-depth, cognitive qualitative interviews with parents to elicit their views on existing screening tools covering social adversities and strengths. We partnered with a local nonprofit to recruit parents who recently had a child hospitalized or visited the emergency department. There were 2 phases of the study. In the first phase, we used qualitative methods to develop a screening prototype. In the second phase, we obtained feedback on the prototype.

RESULTS

We interviewed 18 parents who identified 3 major themes around screening: 1. factors that promote parents to respond openly and honestly during screening; 2. feedback about screening tools and the prototype; and 3. screening should include resources.

CONCLUSIONS

Social adversity routinely affects children; hospitalization is an important time to screen families for adversity and potential coexisting strengths. Using qualitative parent feedback, we developed the family friendly Collaborate to Optimize Parent Experience screening tool.

Trends in utilization of contralateral prophylactic mastectomy among different age, racial and ethnic groups

Background

The use of contralateral prophylactic mastectomy (CPM) has increased over the last two decades with variations in the frequency of reconstruction. The objective of this cohort study is to elucidate the use of CPM and reconstruction among underrepresented racial and ethnic groups and women over 65 years.

Methods

Women over 18 years, diagnosed with stages I to III breast cancer who underwent mastectomy from 2004-2017 were identified in the National Cancer Database (NCDB) and grouped into CPM vs. non-CPM. Multivariable analyses were used to examine the associations between CPM and reconstruction with sociodemographic and clinical factors.

Results

A total of 571,649 patients were identified. Patients who underwent CPM were under 50 years (45.9%), White (88.4%) and with private insurance (73.5%). On multivariable analysis, women over 65 years [odds ratio (OR): 0.18, P<0.001], non-White (Black, OR: 0.56, P<0.001) and without private insurance (uninsured, OR: 0.50, P<0.001) had decreased odds of CPM. Women over 65 years (OR: 0.11, P<0.001), non-White (Asian/Pacific Islander, OR: 0.58, P<0.001) and without private insurance (Medicaid, OR: 0.41, P<0.001) had decreased odds of reconstruction.

Conclusions

Non-White women and women over the age of 65 years were less likely to have CPM or reconstruction than their White counterparts from 2004 to 2017. Research is needed to understand factors impacting decision-making.

Racial and Ethnic Disparities in Peripheral Vascular Disease Admissions Using a Nationally Representative Sample

Our study aimed to identify clinical outcomes and resource utilization associated with race and ethnicity in patients admitted with peripheral vascular disease (PVD) across the United States. We queried the National Inpatient Sample database from 2015 to 2019 and identified 622,820 patients admitted with PVD. Patients across 3 major race and ethnic categories were compared in terms of baseline characteristics, inpatient outcomes, and resource utilization. Black and Hispanic patients were more likely to be younger and of the lowest median income but incur higher total hospital costs. Black race predicted higher rates of acute kidney injury, need for blood transfusion, and need for vasopressor but lower rates of circulatory shock, and mortality. Black and Hispanic patients were less likely to undergo limb-salvaging procedures and more likely to undergo amputation than White patients. In conclusion, our findings indicate that Black and Hispanic patients experience health disparities in resource utilization and inpatient outcomes for PVD admissions.