The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma

Medical provider perspectives on children with incarcerated parents: A mixed-methods study

Purpose

To understand health care providers' perceptions, clinical considerations, and clinical actions towards children with incarcerated parents.

Methods

We implemented an experimental vignette study in which health care provider participants were randomly assigned a patient case describing a child with a parent absent for unspecified reasons (control) vs. incarceration (experimental). Participants completed a survey of closed- and open-ended items regarding their clinical approach. Groups were compared with chi-square and ANOVA. Qualitative data were analyzed inductively.

Results

Medical providers (N = 391) were predominantly non-Hispanic white, male, and physicians who had not received training on social determinants of health. There were no significant differences between the experimental and control groups in comfort with or approach towards the patient; specific conditions of concern; or number of concerns. Across groups, providers commonly endorsed intentions for additional emotional-behavioral screening and concerns for ADHD and adjustment disorders. Providers responding to the experimental vignette indicated interest in the child's psychosocial context (e.g., behavior/attention at home), current experiences (e.g., with trauma or abuse), relationships (e.g., with grandparents), perspectives of other reporters (e.g., teachers), and additional clinical actions (e.g., in-depth medical or developmental history).

Conclusion

Medical providers' approach to children of incarcerated parents may be similar to that of any child with an absentee parent, contrasting existing literature on teachers. When signaled about parental incarceration, providers evidenced attention to children's holistic contexts and needs.

Neighborhood Socioeconomic Deprivation and Length of Stay in Children With Medical Complexity

OBJECTIVE

Children with medical complexity (CMC) often experience long hospital length of stay (LOS). Many families of CMC experience financial and social hardships, which impact arrangement of the home supports necessary for discharge. Understanding neighborhood context in which CMC live is one way to examine the effects of these hardships on LOS. We aimed to evaluate the association between neighborhood socioeconomic deprivation and hospital LOS in CMC.

METHODS

We conducted a single-center retrospective study including hospitalized children aged up to 21 years with 2 or more complex chronic conditions discharged from hospital medicine in 2016 to 2022. We excluded neonatal intensive care hospitalizations. We mapped home addresses to US census-tract data to calculate the primary exposure, the Brokamp neighborhood socioeconomic deprivation index. We used linear mixed models to examine the association between deprivation index and LOS (continuous days), adjusting for covariates (eg, patient clinical characteristics) and accounting for within patient clustering.

RESULTS

We included 4697 encounters from 2186 CMC. The median deprivation index was 0.33 (IQR, 0.25-0.42) and median LOS was 3.29 days (IQR, 1.86-6.91). In adjusted analysis, for each 0.1 increase in deprivation index, LOS increased 1.05-fold (95% CI, 1.03-1.08). Therefore, we expect a 9% increase in LOS for CMC living in more socioeconomically deprived neighborhoods (our cohort's 75th percentile deprivation index: 0.42) vs less deprived neighborhoods (our cohort's 25th percentile deprivation index: 0.25).

CONCLUSIONS

CMC from neighborhoods with greater socioeconomic deprivation experienced longer hospitalizations even when accounting for level of complexity and severity of illness. While the clinical effect is small individually, our results highlight systemic inequities.

Racism and hypothalamic-pituitary-adrenal axis functioning in childhood as risks for health disparities across the lifespan

Racism is a primary social determinant of health and chronic stressor that affects the physical and mental health of People of Color and Indigenous Individuals (POCI) and perpetuates racial and ethnic health disparities. Despite the impact of racism on POCI, the mechanisms through which experiences of racism result in negative health outcomes remain understudied, in particular among children. Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis is one of the possible mechanisms. Frequent and prolonged exposure to chronic stressors may result in dysregulation of the HPA axis, and in turn cause adverse physical and psychological health outcomes for POCI children. This paper argues for the importance of examining HPA axis dysregulation as a mechanism that links racism during early childhood to negative health outcomes over the lifespan. Several studies have explored the relationship between racism and HPA axis dysregulation during adulthood and adolescence and have found associations between racism and salivary and hair cortisol. Recent studies have identified racial and ethnic differences in cortisol levels during early childhood, but only one study, to our knowledge, explored whether the differences are attributed to racism. In this paper, we conduct a review of the existing literature on the links between racism and HPA axis dysregulation during adulthood and adolescence given the dearth of studies exploring this relationship during early childhood. We also highlight the importance of utilizing an intersectionality framework in the study of racism and health to provide a more comprehensive and nuanced understanding of health disparities among and within racial/ethnic groups. Using this evidence along with consideration of relevant models, we propose how HPA axis dysregulation identified early in life may foreshadow children's increased risk for negative health outcomes from racism and other systems of oppression and signal the need for prevention and intervention.

Building an Infrastructure to Address Racial Disparities in Treatment and Outcomes in Children with Type 1 Diabetes

Type 1 diabetes (T1D) is one of the most common chronic diseases in childhood and has many process and outcome metrics that reflect health care quality and clinical outcomes. When compared with non-Hispanic White children, non-Hispanic Black children are less likely to use diabetes technology and are more likely to have suboptimal diabetes control. To develop a meaningful and multi-pronged approach to addressing racial disparities in T1D, we need to understand the drivers of disparities from multiple perspectives. In this article, we describe an approach to integrating the perspectives of caregivers, clinical teams, and the clinical data infrastructure to address racial disparities in T1D.

Racial and Ethnic Differences in ED Analgesia Among Injured Children Transported Via EMS

OBJECTIVES

Pain management remains suboptimal across the prehospital and the emergency department (ED) settings. Racial and ethnic disparities in the timing of analgesia among children transported to EDs via emergency medical services (EMS) are not known. We investigated disparities in the timing of ED pain management for injured children transported by EMS.

METHODS

We conducted a secondary analysis of a multicenter prospective observational study of children transported via EMS to 10 pediatric EDs. We analyzed the timing of ED analgesia for injured children by race and ethnicity: non-Hispanic White (NH-White), non-Hispanic Black (NH-Black), Hispanic, and Other or Multiracial. We stratified doses of ED analgesia by opioids, nonopioids, nonsteroidal anti-inflammatory drugs, and other analgesic medications regardless of routes of administration.

RESULTS

Among 480 eligible injured children, 353 (73.5%) received ED analgesia and 150 (31.3%) received opioid analgesia in the ED after EMS transport. The median time to first administration of any ED analgesia was 39 minutes (range, 2 min to 6 h). Hispanic children received their first dose of any ED analgesia 55 minutes (minimum-maximum, 2 to 369) into their ED care, compared with 38 minutes (4 to 379) for NH-Black, 37 minutes (4 to 345) for NH-White, and 32 minutes (9 to 188) for children of Other or Multiracial groups (P=0.0148). There were no statistical differences in the time to first ED opioid analgesia by race and ethnicity (P=0.3270). Patients with long bone fractures (hazard ratio: 1.56, 1.18-2.06) and those who had received EMS opioids (1.43, 1.07-1.91) were more likely to receive both any analgesia and opioid analgesia in the ED.

CONCLUSIONS

Among injured children across the country transported by EMS to pediatric EDs, there were race and ethnicity differences with respect to time to any ED analgesia; however, no delay for ED opioids. Further research is needed to understand and mitigate potential root causes of these disparities.

Implicit Race Bias in Pediatric Patients: Understanding Patient Perspectives

INTRODUCTION

Implicit racial bias has been well studied in adults, including among orthopaedic surgeons, through the Implicit Association Test (IAT). Recent studies suggest implicit race bias is also present among children. Explicit racial preference has been studied in children through The Clark Doll Test since the 1930s. The purpose of this study was to determine whether implicit and explicit racial biases are present among pediatric orthopaedic patients.

METHODS

A prospective, cross-sectional survey was administered to pediatric orthopaedic patients aged 7 to 18 years at clinics in a tertiary pediatric hospital setting. The survey included a Clark Doll Test to determine whether pediatric patients expressed explicit bias, followed by a race IAT to determine whether pediatric patients expressed implicit bias. Preference and magnitude of implicit bias as demonstrated on the IAT was calculated using standard D-scores.

RESULTS

A total of 96 patients were consented and included in this study. Overall, pediatric patients demonstrated a slight pro-White implicit bias (M = 0.22) on IAT testing. Pediatric patients who identified as White or European American and Hispanic or Latinx both had the strongest pro-White implicit bias (M = 0.35). Patients who identified as Black or African American demonstrated no implicit racial bias (M = -0.13) on IAT testing. No notable explicit bias was observed in participants of any racial background.

DISCUSSION

This study contributes evidence that pediatric orthopaedic patients express implicit racial bias on IAT testing, with an overall slight pro-White bias. It also provides insight into the dissociation of implicit and explicit racial bias in childhood and adolescence.

CONCLUSION

We encourage future research on implicit bias among pediatric patients in the orthopaedic community to provide a better understanding and possible solutions to bias-related challenges in health care.

The Impact of Race and Ethnicity on Location and Delivery of Palliative Radiotherapy

OBJECTIVES

Among patients that underwent palliative RT (pRT) at a single institution, we evaluated whether differences exist across race and ethnicity in location of pRT consultation and delivery of pRT.

METHODS

This retrospective study included cancer patients aged 18 years or older who received pRT between 10/2021 and 10/2022. Logistic regression models were used to examine univariable (UVA) and multivariable (MVA) associations between race and pRT consult in the inpatient (vs. outpatient) setting. A subset analysis of quality metrics for pRT delivery was limited to patients who had outpatient consults for pain.

RESULTS

Four hundred forty patients underwent 548 pRT consults (104 inpatient and 444 outpatient) followed by a course of pRT. Most patients were male (58.2%), White non-Hispanic (WNH) (72.6%), and English-speaking (92.9%). On MVA adjusting for histology, language, and insurance type, consults for Black/African American (BAA) patients had 2.92 higher odds of being performed in the inpatient setting compared with consults for WNH patients (95% CI: 1.28-6.70, P=0.011), although the global P-value was P=0.217. Among 290 outpatient consults for painful lesions, no differences in time to pRT start (global P=0.84), number of prescribed fractions of RT (global P=0.94), or new prescriptions for opioids (global P=0.69) were noted by race and ethnicity.

CONCLUSIONS

In this study, BAA race was associated with the location of pRT consultation, but no discernible differences were noted regarding the outpatient delivery of pRT for pain. These findings support the importance of inpatient pRT programs to ensure equitable access. More research is needed to understand barriers to outpatient consult.

Combating racism in medical education: Problems, definitions, principles and practical steps

Racism remains a significant issue in the medical field, profoundly affecting minority medical students. These students face unique challenges - including microaggressions, implicit biases, systemic barriers, and overt discrimination - impacting their education, mental health, career trajectories, and ability to provide compassionate care. Despite some progress, structural obstacles and underrepresentation persist, highlighting the need for systemic changes. This viewpoint paper explores definitions, principles, and practical steps for fostering antiracist cultures within medical education. It emphasizes the importance of developing self-advocacy, building support networks, and practicing continuous learning for minority students, while advocating for institutional strategies such as creating inclusive spaces, mentorship programs, curriculum reform, and financial support. By combining personal resilience with unwavering institutional support, medical education can move towards true equity and inclusion, ensuring that all students can thrive and contribute to a more equitable healthcare system.

Short-Term Gains, Enduring Potential: An Integrated SDOH-Focused Care Model Delivers Cost Savings and Patient-Reported Benefits

High-need, high-cost (HNHC) adults require comprehensive strategies that address both clinical and social determinants of health (SDOH). This retrospective, propensity score-matched study (n = 526) evaluated a care model integrating monthly SDOH screenings, medication oversight, and real-time admission-discharge-transfer alerts in four urban primary care clinics. Compared to usual care, the intervention significantly reduced acute utilization within 60 days: emergency department (ED) visits decreased by 0.17 (P < 0.001) and hospital admissions declined by 0.12 (P < 0.001). Gross per-participant costs fell from $6,019 to $2,422 (a $3,597 reduction); after accounting for intervention expenses, net savings reached $3,222 (P < 0.001), yielding an estimated 6.9:1 return on investment. Patient-reported outcomes also demonstrated significant gains: EQ-5D-5L scores increased by 0.082 (P < 0.001) in the intervention cohort, exceeding the threshold for clinically meaningful change, while Net Promoter Scores rose by 8.8 points (P < 0.001). Subgroup analyses revealed slightly smaller quality-of-life gains among non-White cohorts, highlighting the need for culturally tailored approaches to advance equity. These findings align with prior Population Health Management research showing that integrated care models can reduce costs and enhance patient satisfaction. Overall, this multifaceted model effectively curbs avoidable ED visits and admissions, generates short-term cost savings, and boosts patient satisfaction-key outcomes under value-based care contracts. Future research should investigate longer-term outcomes and refine equity-focused strategies to ensure sustained and inclusive benefits.

Study protocol for investigating racial disparities in pain care: a comprehensive integration of patient-level and provider-level mechanisms with dyadic communication processes using a mixed-methods research design

INTRODUCTION

Although many efforts have been made to reduce racial pain disparities over decades, the pain of black patients is still undertreated. Previous work has identified a host of patient and provider factors that contribute to racial disparities in healthcare in general, and consequently, may contribute to disparities in pain care in particular. That said, there has been limited clinically meaningful progress in eliminating these disparities. This lack of progress is likely because prior research has investigated the influence of patient and provider factors in isolation, rather than examining their interaction. Successful pain care requires constructive patient-provider communication, and constructive communication is both dyadic and dynamic. One well-accepted operationalisation of such dyadic processes is behavioural coordination. We hypothesise that the pain of black patients continues to be undertreated because black patients are more likely than white patients to participate in racially discordant medical interactions (ie, seeing other-race providers) and experience disruptions in behavioural coordination. We further hypothesise that disruptions in behavioural coordination will reflect patient and provider factors identified in prior research. We propose to test these hypotheses in the planned surgical context.

METHODS AND ANALYSIS

Using a convergent mixed methods research design, we will collect data from at least 15 surgeons and their 150 patients (approximately equal number of black and white patients per surgeon). The data sources will include one surgeon survey, four patient surveys, video- and/or audio-recordings of preoperative consultations and medical chart reviews. The recorded preoperative consultations will be analysed both qualitatively and quantitatively to assess the magnitude and pattern of behavioural coordination between patients and surgeons. Those data will be linked to survey data and data from medical chart reviews to test our hypotheses.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Virginia Commonwealth University Institutional Review Board (HM20023574). Findings will be disseminated through presentations at scientific conferences, publications in peer-reviewed journals and speaking engagements with clinician stakeholders. We will also share the main findings from this project with patients via a newsletter on completion of the entire project.

Identifying characteristics associated with genetic testing in the NICU

Genetic testing is an integral part of Neonatal Intensive Care Unit (NICU) care. There are reported disparities in both NICU care and genetic testing related to race and language spoken. Identifying characteristics associated with genetic testing in NICUs could help detect patients who may benefit from genetic testing, as well as any current disparities. We sought to analyze characteristics of NICU admits who had genetic testing in general and specific test categories. Characteristics were requested from the Children's Hospital Neonatal Consortium database for patients admitted to Primary Children's Hospital's NICU in 2022. Statistical analysis was performed to determine if characteristics were more likely to result in genetic testing and if differences between those with genetic testing and those without were significant. All genetic test types were more likely ordered with genetic consultations. Cytogenetic testing was more likely in patients with a cardiology consult or who were Spanish-speaking. Patients who were of Hispanic origin were more likely to have molecular testing ordered. The average number of specialty consults for a patient was higher for those with genetic testing. Premature and low birthweight infants had longer time to genetic test ordering. No disparities were identified, which could be due to a small, homogenous sample. The differences with Spanish-speaking patients and those with mothers of Hispanic origin could be due to many factors, including consenting practices. It may be difficult to identify infants who might need genetic testing when they are low birthweight and/or premature. It is important to continue monitoring for differences in ordering practice for this vulnerable population.

Defensive Responses to Implicit Association Tests and Bias Awareness in an Implicit Bias Mitigation Training

Background

Implicit bias education that utilizes the Implicit Association Test (IAT) to raise self-awareness of bias can induce defensiveness.

Objective

To describe clinical learners' bias awareness, self-perceptions of bias relative to colleagues (better-than-average), implicit and explicit biases and defensive response to the IATs.

Design

Cross-sectional study.

Participants

Internal medicine and family medicine residents, and Doctor of Nursing Practice students at a public medical and nursing school affiliated with a disproportionate share hospital and who completed an implicit bias recognition and mitigation educational program (including didactics, IATs, and communication skills training and practice with standardized patients) in 2018-2019.

Main Measures

We measured implicit and explicit attitudes and stereotypes, reactions to IAT results (defensive or not defensive), better-than-average perceptions, bias awareness and participants' characteristics. We examined associations between defensive responses to the IAT and participant characteristics, self-reported explicit biases, bias awareness within self, society, and healthcare, and IAT scores.

Key Results

Of N=61 respondents, 57% were female and 59% White. We found moderate implicit bias favoring White people versus Black people, weak bias favoring White people versus Hispanic/Latinx people and moderate bias favoring White people on both race and ethnicity medical compliance stereotype IATs. Participants demonstrated awareness of bias in society and healthcare, but not within self. Eighteen percent were defensive regarding their IAT results. Perceptions of own bias (self) were always of their having less bias than their colleagues, and they were better-than-average. There were no statistically significant associations between IAT scores and participant demographics and no interaction effect between implicit bias, defensiveness and better-than-average scores.

Conclusion

Clinical learners hold moderate implicit biases, believe they have less bias than others, and almost 1-in-5 have a defensive response to IAT feedback. It is important to design implicit bias educational interventions to include reflection on personal bias and provide a safe environment to minimize defensiveness.

Race and gender biases in assessing pain intensity and medication needs among Chinese observers

Introduction

Pain-related decision-making can be influenced by the caregiver and sufferer's demographic factors, such as race and gender, which are commonly considered individually. However, such factors may influence pain assessment interdependently based on caregivers' stereotypical beliefs.

Objectives

This study investigated how sufferers' race and gender affect Chinese observers' evaluations of pain intensity and medication needs and the associations with the observers' race and gender-related stereotypical beliefs.

Methods

One hundred sixty-two Chinese participants completed a pain facial expression rating task assessing the level of pain intensity and the extent to which they believe the sufferer needs pain medication for East Asian, White, and Black sufferers, followed by a battery of questionnaires measuring their gender and race role expectation of pain.

Results

Chinese observers were more stringent on East Asians' pain intensity and needs for medication than Whites and Blacks'. However, when Black and East Asian sufferers were perceived to have a similar level of pain, East Asians were more likely to receive medication than Blacks, which is partly due to the observers' stereotypical beliefs that Blacks would have a speedier recovery than East Asians.

Conclusions

Our results provided evidence that in addition to the in-versus-out-group preferences, one's sociocultural-related stereotypical beliefs can account for racial disparities in pain-related decision-making.

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.

Beyond Tuskegee: A contemporary qualitative assessment of barriers to research participation among Black women

BACKGROUND

Health care inequities have partially contributed to the existing racial gaps in health. Despite having lower incidence rates of breast cancer, Black women have a 41% higher mortality rate than White women. Black individuals remain underrepresented in research. Diversity in research is paramount to the improvement of clinical care practices and subgroup-specific guidelines.

METHODS

Black women from various community venues across geographic regions of the United States were invited via email, online fliers, social media platforms, and word of mouth to participate in focus groups. Six online focus groups of six to 10 Black women aged 25-65 years (N = 38) with and without a history of cancer were conducted with an in-depth semistructured discussion guide.

RESULTS

Most participants were college educated (32 of 38; 84.2%), aged 50 years or older (31 of 38; 81.6%), and had an annual income of $50,000 or more (26 of 38; 68.4%). Several barriers to research participation were identified. They included a lack of empathy and respect in health care settings, apprehension regarding the sharing of personal information, mistrust of medical research, and logistical/technical barriers. Alternatively, building individual and community trust and communicating the value of conducting research beneficial to the Black community were viewed as facilitators to research participation.

CONCLUSIONS

Successful engagement of Black women in research requires the acknowledgment and consideration of the numerous barriers that affect their ability to participate. Black women are more inclined to participate in research when the research team is knowledgeable, has experience within their communities, and engages trusted community partners. Additionally, the research must be meaningful and impactful to future generations of Black women.

Biased Language in Simulated Handoffs and Clinician Recall and Attitudes

Importance

Poor-quality handoffs can lead to medical errors when transitioning patient care. Biased language within handoffs may contribute to errors and lead to disparities in health care delivery.

Objective

To compare clinical information recall accuracy and attitudes toward patients among trainees in paired cases of biased vs neutral language in simulated handoffs.

Design, Setting, and Participants

Surveys administered from April 29 to June 15 and from July 20 to October 10, 2023, included 3 simulated verbal handoffs, randomized between biased and neutral, and measured clinical information recall, attitudes toward patients, and key takeaways after each handoff. Participants included residents in internal medicine, pediatrics, and internal medicine-pediatrics and senior medical students at 2 academic medical centers in different geographic regions of the US. Data were analyzed from November 2023 to June 2024.

Exposures

Each participant received 3 handoffs that were based on real handoffs about Black patients at 1 academic center. These handoffs were each randomized to either a biased or neutral version. Biased handoffs had 1 of 3 types of bias: stereotype, blame, or doubt. The order of handoff presentation was also randomized. Internal medicine and pediatrics residents received slightly different surveys, tailored for their specialty. Internal medicine-pediatrics residents received the pediatric survey. Medical students were randomly assigned the survey type.

Main Outcomes and Measures

Each handoff was followed by a clinical information recall question, an adapted version of the Provider Attitudes Toward Sickle Cell Patients Scale (PASS), and 3 free-response takeaways.

Results

Of 748 trainees contacted, 169 participants (142 residents and 27 medical students) completed the survey (23% overall response rate), distributed across institutions, residency programs, and years of training (95 female [56%]; mean [SD] age, 28.6 [2.3] years). Participants who received handoffs with blame-based bias had less accurate information recall than those who received neutral handoffs (77% vs 93%; P = .005). Those who reported bias as a key takeaway of the handoff had lower clinical information recall accuracy than those who did not (85% vs 93%; P = .01). Participants had less positive attitudes toward patients per PASS scores after receiving biased compared with neutral handoffs (mean scores, 22.9 [3.3] vs 25.2 [2.7]; P < .001). More positive attitudes toward patients were associated with higher clinical information recall accuracy (odds ratio, 1.12; 95% CI, 1.02-1.22).

Conclusions and Relevance

In this survey study of residents and medical students, biased handoffs impeded accurate transfer of key clinical information and decreased empathy, potentially endangering patients and worsening health disparities. Handoff standardization is critical to addressing racial bias and improving patient safety.

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.

Navigating Pediatric Pain: Emerging Trends and Best Practice

This article examines the pivotal role of critical care nurses in managing pediatric pain, emphasizing the multifaceted nature of care. It covers the challenges and opportunities nurses face, stressing the importance of education and training. The background section underscores the global issue of inadequately managed pediatric pain and the importance of addressing social determinants of health while recognizing perceptions, beliefs, stereotypes, and biases on pain management. A multimodal approach in treatment is detailed in pharmacologic and non-pharmacologic approaches. Barriers nurses encounter are discussed, with recommendations for a holistic and individualized approach to pediatric pain management in critical care settings.

Variation in Mentions of Race and Ethnicity in Notes in Intensive Care Units Across a Health Care System

BACKGROUND

Social constructs like race can affect how patients are perceived and impact care. This study investigated whether mentions of race in notes for critically ill patients differed according to patients' race.

METHODS

This retrospective cohort study included intensive care unit notes for adults (≥18 years old) admitted to any of 6 intensive care units at University of California, San Francisco, from 2012 through 2020. Notes were linked to National Provider Identifier records to obtain note writer characteristics. Logistic regression analysis with robust SEs clustered on note writers was adjusted for patient-, note- and clinician-level characteristics. Any race or ethnicity mention was the outcome of interest.

RESULTS

Among 5573 patients with 292 457 notes by 9742 unique note writers, 3225 patients (57.9%) self-reported their race as White, 997 (17.9%) as Asian, 860 (15.4%) as Latinx, and 491 (8.8%) as Black. Note writers documented race/ethnicity for 20.8% of Black, 10.9% of Latinx, 9.1% of White, and 4.4% of Asian patients. Black patients were more likely than White patients to have race mentioned in notes (adjusted odds ratio, 2.05 [95% CI, 1.49-2.82]).

CONCLUSIONS

Black patients were more than twice as likely as White patients to have race mentioned in notes. Note language containing information on social constructs has consequences for clinicians and patients reading notes and for algorithms trained on clinical notes.

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.

Applying a health equity lens to the perioperative anesthetic management for coronary artery bypass grafting

BACKGROUND

Disparities in healthcare based on race, ethnicity, and socioeconomic status (SES) remain a public health crisis, especially in perioperative anesthetic management. This study applies a health equity lens to intraoperative pain and postoperative nausea and vomiting (PONV) for patients undergoing coronary artery bypass grafting (CABG).

METHODS

This retrospective cohort study included 1404 adult patients who underwent coronary artery bypass grafting (CABG) between 2017 and 2022 at a single, multi-site, academic healthcare system. The primary outcomes were PONV as well as moderate-to-severe post-operative pain. Secondary outcomes were administration of prophylactic antiemetics, compliance with guideline-recommended antiemetic prophylaxis, and opioid morphine milligram equivalents (MME) administered intraoperatively. Independent variables included patient race and ethnicity, healthcare payor type, and community-level SES (using Area Deprivation Index [ADI]). Multivariable logistic regression models that controlled for relevant covariates were utilized.

RESULTS

The findings showed no significant disparities in experiencing PONV, post-operative pain, or receiving high opioid MME based on race, ethnicity, payor type, and ADI. There were also no differences in the receipt of antiemetics nor compliance with guideline-recommended antiemetic prophylaxis.

CONCLUSIONS

Our study did not find racial, ethnic, or SES disparities in intraoperative anesthetic pain management, postoperative pain, nor PONV management. Applying a health equity lens to quality outcomes during the perioperative period is necessary to ensure equitable care among diverse populations.

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.

Triage Discordance in an Academic Pediatric Emergency Department and Disparities by Race, Ethnicity, and Language for Care

BACKGROUND

Minoritized patients are disproportionately represented in low-acuity emergency department (ED) visits in the United States in part caused by lack of timely access to primary and urgent care. However, there is also the possibility that implicit bias during triage could contribute to disproportionate representation of minority groups in low-acuity ED visits. Triage discordance, defined as when ED resources used are different from initial triage score predictions, can be used as a proxy for triage accuracy. Recent data suggest that discordant triage may be common, although little is known about the interaction with race, ethnicity, and language for care.

OBJECTIVES

This study aims to determine the prevalence of discordant triage among moderate- and low-acuity pediatric ED encounters and the interaction with patient race, ethnicity, and language for care.

METHODS

We performed a retrospective analysis of pediatric ED encounters from 2019 with Emergency Severity Index (ESI) scores of 3, 4, or 5 at an academic referral hospital. The primary outcome was triage discordance, encompassing overtriage (ESI 3 and 4) and undertriage (ESI 4 and 5). Logistic and multinomial regressions were used to assess discordant triage by race, ethnicity, and language group.

RESULTS

Triage discordance occurred in 47% (n = 18,040) of encounters. Black and Hispanic patients had higher likelihood of undertriage for ESI 5 (adjusted odds ratio 1.21, 95% confidence interval [CI] 1.01-1.46 and 1.27, 95% CI 1.07-1.52, respectively), and Black patients were more likely to be overtriaged in ESI 3 (1.18, 95% CI 1.09-1.27). Those with a language other than English for care had higher proportions of overtriage for ESI 3 (1.08, 95% CI 1.04-1.12) and undertriage for ESI 5 (1.23, 95% CI 1.11-1.37).

CONCLUSIONS

We found high rates of triage discordance in our pediatric ED, with significant associations with race, ethnicity, and language for care. Future research should evaluate the source of triage discordance and develop quality improvement efforts to improve equitable care.

Race and Ethnicity and Clinician Linguistic Expressions of Doubt in Hospital Admission Notes

Importance

Stigmatizing language in electronic health records (EHRs) can generate or reinforce negative stereotypes about patients from minoritized groups and erode their trust and experience. However, less is known about the use of such language to cast doubt on patient clinical history in hospital settings.

Objective

To compare the prevalence of language expressing doubt about patient clinical history (eg, experiences and symptoms) in hospital admission notes by patient race and ethnicity.

Design, Setting, and Participants

In this cohort study, natural language processing tools were applied to analyze 54 936 admission notes from 1249 clinicians about patients aged 18 years or older at admission and hospitalized at an academic health system in the Northeast US between January 1, 2018, and February 28, 2023. Data were analyzed from September 1, 2022, to July 31, 2023.

Exposure

Patient race and ethnicity (non-Hispanic Black, non-Hispanic White, and racial and ethnic minoritized groups excluding non-Hispanic Black [includes multiple racial and ethnic groups, such as Hispanic and Asian]) as recorded in the EHR based on self-report or registrar determination.

Main Outcome and Measure

Binary indicator for at least 1 term casting doubt on patient clinical history was defined using epistemic stance, a linguistic construct expressing a writer's degree of certainty in information. Terms were manually validated via iterative review of notes by the study team.

Results

Among 56 325 admission notes (mean [SD] age of patients, 55.9 [19.0] years; 30 913 notes among female patients [54.9%]; 25 649 notes among non-Hispanic Black patients [45.5%], 26 442 notes among non-Hispanic White patients [46.9%], and 2985 notes among members of racial and ethnic minoritized groups excluding non-Hispanic Black patients [5.3%]), we analyzed 54 936 admission notes that had no missing data. Among all analyzed admission notes, 39 023 notes (71.0%) contained doubt language. Notes written about non-Hispanic Black patients had increased odds of containing at least 1 word or phrase of doubt (adjusted odds ratio, 1.21; 95% CI, 1.14-1.28; P < .001) compared with notes among non-Hispanic White patients. Compared with notes among non-Hispanic White patients, notes written about members of racial and ethnic minoritized groups excluding non-Hispanic Black patients had similar odds of containing at least 1 term of doubt.

Conclusion and Relevance

In this study, language casting doubt on patient clinical history was more likely to be found in notes of non-Hispanic Black patients. These results suggest that with the implementation of policies allowing patients full access to their health records, examining clinical documentation standards may be associated with improved patient experience.

Assessing pain in older people with normal, mildly impaired or severely impaired cognition

Pain is a relatively common experience among older people, but unrelieved pain has significant functional, cognitive and emotional consequences for this population. A comprehensive and accurate pain assessment is essential for effective pain management. Self-report tools are suitable to assess pain in older people with normal or mildly impaired cognition, while observational tools are suitable for use with those with significant cognitive impairment or communication difficulties. However, pain assessment in older people can be challenging. The use of one tool on its own is rarely sufficient and it is crucial to involve family carers in assessment of pain in older people with severe cognitive impairment. This article discusses different tools and strategies, including the benefits and limitations, for assessing pain in older people.

Improving Pain Management for Marginalized Communities: Educating the Next Generation of Health Care Professionals

Inadequately managed pain has immense negative impacts on children, families, health care systems, and societies. Historically and presently, inadequately treated pain disproportionally affects marginalized communities. Deficiencies in pain education for health care providers are widely recognized as a leading contributor to poorly managed pain. Existing training for providers prioritizes physiological systems and pharmacological interventions for pain, despite decades of evidence supporting the biopsychosocial model and interdisciplinary treatment of pain. Moreover, education for health care providers rarely acknowledges the role of bias, prejudice, and systemic racism in perpetuating disparities in pain care. To address this gap, we sought to develop an innovative curriculum for health care teams to combat racial injustice related to pain management. This curriculum was developed and refined collaboratively with community partners representing diverse expertise, including lived experiences of pain, interdisciplinary pain management, cultural humility and authentic allyship, and curriculum development and evaluation. Four modules delivered across 1 to 2 hours were developed and pilot-tested extensively with multidisciplinary providers across a large pediatric health system. Learner feedback indicated high acceptability and informed iterative changes to the curriculum. Additional research is needed to examine impacts of the curriculum on health care provider knowledge and behavior (eg, clinical decision-making) and patient-reported outcomes as well as to test dissemination and implementation strategies. PERSPECTIVE: We present the development and evaluation of a curriculum for health care professionals to combat racial injustice in pain management. By engaging diverse community partners, using design thinking, applying an antiracist lens, and designing for dissemination, we aim to equip the next generation of providers to deliver equitable pain care.

The Importance of Discussing the History of Racism in Medical Student Education

Racial health disparities are tightly linked to the longstanding and pervasive institution of racism. Efforts to reverse disparities begin with awareness and accountability through education. The health care workforce must be formally educated about racist practices, tools, and ideologies that perpetuate poor health outcomes. This article explores prior efforts to integrate race didactics into medical school education, addresses current legislation, and illuminates lessons learned from a single institution pilot curriculum exploring the history of racism in the field of obstetrics and gynecology. Educating medical school students about the history of racism is an important and necessary tool for positive change.

Racial Bias in Pediatric Pain Perception

Racial disparities in pediatric pain care are prevalent across a variety of health care settings, and likely contribute to broader disparities in health, morbidity, and mortality. The present research expands on prior work demonstrating potential perceptual contributions to pain care disparities in adults and tests whether racial bias in pain perception extends to child targets. We examined the perception and hypothetical treatment of pain in Black and White boys (experiment 1), Black and White boys and girls (experiment 2), Black and White boys and adult men (experiment 3), and Black, White, Asian, and Latinx boys (experiment 4). Across this work, pain was less readily perceived on Black (vs White) boys' faces-though this bias was not observed within girls. Moreover, this perceptual bias was comparable in magnitude to the same bias measured with adult targets and consistently predicted bias in hypothetical treatment. Notably, bias was not limited to Black targets-pain on Hispanic/Latinx boys' faces was also relatively underperceived. Taken together, these results offer strong evidence for racial bias in pediatric pain perception. PERSPECTIVE: This article demonstrates perceptual contributions to racial bias in pediatric pain recognition. Participants consistently saw pain less readily on Black boys' faces, compared with White boys, and this perceptual bias consistently predicted race-based gaps in treatment. This work reveals a novel factor that may support pediatric pain care disparities.

Understanding Implicit Bias and Its Impact in Veterinary Medicine

Implicit biases are those we are unwilling to admit, yet they influence our behavior in ways that impact our experience in the workplace. Literature demonstrates that implicit bias influences career choice and limits success within a chosen career. Discrimination in the veterinary workplace is pervasive and has a negative impact that is responsible for financial loss. It can also influence client communication, patient-care, and be inadvertently perpetuated by well-meaning community clinics. Strategies can be employed to acknowledge implicit bias and to foster behavioral change, which results in a healthier workplace and improved client and patient-care.

Racial and Ethnic Disparities in Otolaryngology Office Visit and Tympanostomy Tube Placement in Children with Otitis Media

OBJECTIVES

Racial disparities are pervasive in access to pediatric surgery. The goal of this study was to test the hypotheses that, compared with White children, non-White and Hispanic children: (1) were less likely to attend evaluations by otolaryngologists after a diagnosis of otitis media (OM) eligible for surgical referral, and (2) these children were less likely to receive tympanostomy tube (TT) after surgical consultation.

METHODS

The OptumLabs Data Warehouse is a de-identified claims database of privately insured enrollees. Guidelines on the management of OMs suggest that children should be evaluated for surgery if they have recurrent acute OM or chronic OM with effusion. A cohort of children who were diagnosed with OM were constructed. For Hypothesis 1, the primary outcome was otolaryngology office visit within 6 months of a diagnosis of recurrent or chronic OM. For Hypothesis 2, the outcome was TT placement within 6 months following the otolaryngology office visit. Cox regression models were used to determine the relationship between race/ethnicity and the primary outcomes.

RESULTS

Among 187,776 children with OMs, 72,774 (38.8%) had otolaryngology visits. In a multivariate Cox model, the hazard ratios of attending otolaryngology visit for Black, Hispanic, and Asian children were 0.93 (95% CI,0.90, 0.96), 0.86 (0.83, 0.88), and 0.74 (0.71, 0.77), compared with White children. Among the children evaluated by otolaryngologists, 46,554 (63.97%) received TT. Black, Hispanic, and Asian children with recurrent acute OM had lower likelihood of receiving TT.

CONCLUSIONS

Racial disparities in attending otolaryngology office visit contributed to the disparities in receiving TT.

QUALITY OF EVIDENCE

Level 3 Laryngoscope, 134:3846-3852, 2024.

Provider Implicit Racial Bias in Pediatric Sickle Cell Disease

BACKGROUND/OBJECTIVES

This study is to (1) assess implicit racial bias among pediatric providers and (2) use virtual patient (VP) vignettes to determine the impact of implicit racial bias on clinical decision-making in pediatric sickle cell disease (SCD) pain care.

DESIGN/METHODS

This cross-sectional study was conducted at a mid-sized, freestanding children's hospital in the northeast. Participants (N = 52) were pediatric SCD providers (87% cisgender female, 90% White, M age = 38.78). Providers completed a demographic questionnaire, the race Implicit Association Test (IAT) with adult and child faces, and a measure of SCD explicit bias (5-point Likert scale). Providers also made clinical decisions for four VP vignettes depicting Black and White youth in the emergency department (ED) with either SCD or cancer pain. Frequency tables were calculated.

RESULTS

On the race IAT, providers demonstrated a pro-White implicit bias for both adult (81%) and child (89%) faces. Responses to the explicit bias measure reflected low levels of agreement with negative stereotypes about SCD patients. No significant differences emerged in providers' pain treatment decisions for Black vs. White, or SCD vs. cancer VPs.

CONCLUSIONS

Findings indicate pediatric providers harbor implicit racial bias similar to the general population. Findings from VP vignettes did not demonstrate that pain treatment decision-making differed based on race or diagnosis. This may be due to standardized protocols and procedures in the pediatric emergency setting. Future research is needed to clarify the role of implicit bias in clinical decision-making and the potential efficacy of treatment protocols in preventing biases from interfering with pediatric SCD pain care.

Trends in Repeat Opioid Analgesic Prescription Utilization for Acute Pain in Children: 2013-2018

OBJECTIVE

Our study examined the change in repeat opioid analgesic prescription trends in children and adolescents experiencing acute pain between 2013 and 2018.

METHODS

Eligible individuals were children and adolescents between 1 and 17 years of age enrolled in a Medicaid Managed Care plan and filled an incident opioid analgesic prescription from 2013 to 2018. A repeat opioid prescription was defined as receiving a subsequent opioid prescription within 30 days from the end of the incident opioid prescription. A generalized linear regression analysis was conducted to examine changes in repeat opioid analgesic dispensing over time at quarterly intervals from January 1, 2013, to December 31, 2018.

RESULTS

The cohort comprised 17,086 children and adolescents receiving an incident opioid analgesic. Of these, 1780 (10.4%) filled a repeat opioid analgesic prescription. There was a significant decline in the repeat opioid analgesic trend from 11.5% in Q1 2013 to 9.6% in Q4 2018. Stratified analyses by age, sex, and race and ethnicity in a sub-cohort of patients undergoing surgical procedures showed that a significant decline in repeat opioid utilization over time has been observed in all racial/ethnic groups stratified by age and sex, with the most significant decline found in non-Hispanic White children and Hispanic adolescents. At the end of the 6-year follow-up, the racial and ethnic variations in repeat opioid utilization associated with surgical procedures had significantly reduced in children yet persisted among adolescents.

CONCLUSIONS

Approximately 10% of incident pediatric opioid analgesic recipients received a repeat opioid prescription. There has been a moderate but steady decline (∼7% per quarter) in repeat opioid analgesic utilization between 2013 and 2018.

Enrollment of Black, Indigenous and People of Color (BIPOC) and female participants in the US diabetes trials spanning 2000 to 2020: A chronological survey

AIMS

Little is known about the enrollment practice of both Black, Indigenous and People of Color (BIPOC) and females in the US diabetes trials. We aimed to perform a chronological survey to evaluate the enrollment of BIPOC and female participants in the US diabetes randomized controlled trials (RCTs) over the past two decades.

METHODS

We searched databases to systematically include the US diabetes RCTs from 2000 January 1st to 2020 December 31st. Primary outcome was the adequate enrollment of both BIPOC and females, defined by the participation to prevalence ratio (PPR) > 0.8. We tested the temporal trend in adequate enrollment over time and used logistic regression analysis to explore the relationship between adequate enrollment and trial characteristics.

RESULTS

A total of 69 US diabetes trials were included for analyses, with a median BIPOC and female enrollment percentage of 29.0 % and 45.4 % respectively. There were 22 (31.9 %) trials with adequate enrollment of both BIPOC and females. No significant trend of adequate enrollment percentage of BIPOC and females over time was observed (P = 0.16). Of trial types, those with medication interventions were significantly related to decreased odds of adequate enrollment, when compared to trials with non-drug interventions (odds ratio = 0.29, 95 % confidence interval: 0.11-0.84).

CONCLUSIONS

Less than one third of the US diabetes trials adequately enrolled both BIPOC and females over the past two decades, and no temporal improvement in BIPOC and female participant enrollment was observed. These results highlight the need for more endeavors to mitigate inadequate representation regarding BIPOC and female enrollment in diabetes trials.

Race and Gender Differences in Pediatric Milestone Levels: A Multi-Institutional Study

The Accreditation Council for Graduate Medical Education milestones assess resident competency in 6 domains. We hypothesized that disparities in milestones exist across race and gender in pediatric residencies. This is a retrospective, cross-sectional, multi-institutional study (3 pediatric residencies, 1446 scores; 316 residents). African American residents received the lowest scores in patient care (PC) (P = .030), medical knowledge (MK) (P = .005), practice-based learning and improvement (PBLI) (P = .003), professionalism (PROF) (P < .001), and interpersonal communication skills (ICS) (P = .005). Differences were most pronounced in PROF (African American mean 3.35 [SD .75], Asian 3.51 (.66), Hispanic 3.58 (.66), white 3.59 (.67)). Female residents received higher scores than male residents in PC (P = .002) and system-based practice (SBP) (P = .049). Female interns received higher MK scores, 2.53 (.44) versus 2.48 (.48), P = .044, but lower scores as third years, 4.00 (.43) versus 4.14 (.45), P = .030. In this study, pediatric milestones differed based on race and gender.

Design and pilot test of an implicit bias mitigation curriculum for clinicians

Introduction

Clinician implicit racial bias (IB) may lead to lower quality care and adverse health outcomes for Black patients. Educational efforts to train clinicians to mitigate IB vary widely and have insufficient evidence of impact. We developed and pilot-tested an evidence-based clinician IB curriculum, "REACHing Equity."

Methods

To assess acceptability and feasibility, we conducted an uncontrolled one-arm pilot trial with post-intervention assessments. REACHing Equity is designed for clinicians to: (1) acquire knowledge about IB and its impact on healthcare, (2) increase awareness of one's own capacity for IB, and (3) develop skills to mitigate IB in the clinical encounter. We delivered REACHing Equity virtually in three facilitated, interactive sessions over 7-9 weeks. Participants were health care providers who completed baseline and end-of-study evaluation surveys.

Results

Of approximately 1,592 clinicians invited, 37 participated, of whom 29 self-identified as women and 24 as non-Hispanic White. Attendance averaged 90% per session; 78% attended all 3 sessions. Response rate for evaluation surveys was 67%. Most respondents agreed or strongly agreed that the curriculum objectives were met, and that REACHing Equity equipped them to mitigate the impact of implicit bias in clinical care. Participants consistently reported higher self-efficacy for mitigating IB after compared to before completing the curriculum.

Conclusions

Despite apparent barriers to clinician participation, we demonstrated feasibility and acceptability of the REACHing Equity intervention. Further research is needed to develop objective measures of uptake and clinician skill, test the impact of REACHing Equity on clinically relevant outcomes, and refine the curriculum for uptake and dissemination.ClinicalTrials.gov ID: NCT03415308.

Exploring discrimination and racism in healthcare: a qualitative phenomenology study of Dutch persons with migration backgrounds

OBJECTIVE

To explore and characterise the discrimination and racism experienced in healthcare from the perspective of Dutch patients with a migration background.

DESIGN

This was a qualitative phenomenological study incorporating an inductive thematic analysis of the answers provided to a free form online survey. Descriptive and differential analyses were conducted for the closed-ended questions.

SETTING

This study used an online survey distributed in Dutch about experiences of discrimination and racism in healthcare to the general population in the Netherlands.

PARTICIPANTS

The survey was completed by 188 participants (Mage=39.89, SDage=10.2). Of whom 80 (Mage=37.92, SDage=10.87) met the eligibility criteria for thematic analysis (ie, has a migration background or a relative with a migration background and experienced discrimination in healthcare based on their background) and were thus included in the analysis.

RESULTS

From the total sample, women, relative to men, were 2.31 times more likely to report experiencing healthcare discrimination (OR=2.31; 95% CI 1.23 to 4.37). The majority of the participants (60.1%) had a Moroccan or Turkish background. Six themes were identified relating to experienced discrimination in healthcare based on one's migration background: (1) explicit discrimination, (2) prejudice, (3) not being taken seriously, (4) discriminatory behaviour, (5) language barriers and (6) pain attribution to cultural background. Some participants reported that their attire or religion was linked to their migration background, thus contributing to their experiences of discrimination.

CONCLUSION

Dutch patients with a migration background may experience discrimination based on their ethnic identity or other factors related to their backgrounds, such as their faith, culture and skin colour. Discrimination manifests as intersectional and may take different forms (eg, discrimination based on the intersection between race and gender). Therefore, healthcare discrimination may increase health inequities and lead to unequal access to healthcare services. Implicitly or explicitly discriminating against patients is immoral, unethical, illegal and hazardous for individual and public health. Further research on the magnitude of discrimination in healthcare and its relation to health is needed.

Risk Factors for Deterioration Events in the Pediatric Acute Care Setting

OBJECTIVES

Rapid response system (RRS) activations resulting in emergency transfers (ETs) and codes outside the ICU are associated with increased mortality and length of stay. We aimed to evaluate the patient and care team characteristics of RRS activations resulting in ETs and codes outside the ICU (together classified as "deterioration events") versus those that did not result in a deterioration event.

METHODS

For each RRS activation at our institution from 2019 to 2021, data were gathered on patient demographics and medical diagnoses, care team and treatment factors, and ICU transfer. Descriptive statistics, bivariate analyses, and multivariable logistic regression using a backward elimination model selection method were performed to assess potential risk factors for deterioration events.

RESULTS

Over the 3-year period, 1765 RRS activations were identified. Fifty-three (3%) activations were deemed acute care codes, 64 (4%) were noncode ETs, 921 (52%) resulted in nonemergent transfers to an ICU, and 727 (41%) patients remained in an acute care unit. In a multivariable model, any complex chronic condition (adjusted odds ratio, 6.26; 95% confidence interval, 2.83-16.60) and hematology/oncology service (adjusted odds ratio, 2.19; 95% confidence interval, 1.28-3.74) were independent risk factors for a deterioration event.

CONCLUSIONS

Patients with medical complexity and patients on the hematology/oncology service had a higher risk of deterioration events than other patients with RRS activations. Further analyzing how our hospital evaluates and treats these specific patient populations is critical as we develop targeted interventions to reduce deterioration events.

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.

Piloting racial bias training for hospital emergency department providers treating patients with opioid use disorder

Racial disparities in opioid overdose have increased in recent years. Several studies have linked these disparities to health care providers' inequitable delivery of opioid use disorder (OUD) services. In response, health care policymakers and systems have designed new programs to improve equitable OUD care delivery. Racial bias training has been 1 commonly utilized program. Racial bias training educates providers about the existence of racial disparities in the treatment of people who use drugs and the role of implicit bias. Our study evaluates a pilot racial bias training delivered to 25 hospital emergency providers treating patients with OUDs in 2 hospitals in Detroit, Michigan. We conducted a 3-part survey, including a baseline assessment, post-training assessment, and a 2-month follow-up to evaluate the acceptability and feasibility of scaling the racial bias training to larger audiences. We also investigate preliminary data on changes in self-awareness of implicit bias, knowledge of training content, and equity in care delivery to patients with OUD. Using qualitative survey response data, we found that training participants were satisfied with the content and quality of the training and especially valued the small-group discussions, motivational interviewing, and historical context.

The Impact of Foreign Language Accent on Expert Listeners' Auditory-Perceptual Evaluations of Dysphonia

INTRODUCTION

Auditory-perceptual evaluations of dysphonia, though essential for comprehensive voice evaluation, are subject to listener bias. Knowledge of an underlying voice disorder can influence auditory-perceptual ratings. Accented speech results in increased listener effort and delays in word identification. Yet, little is known about the impact of foreign language accents on auditory-perceptual ratings for dysphonic speakers. The purpose of this work was to determine the impact of a foreign language accent on experts' auditory-perceptual ratings of dysphonic speakers.

METHODS

Twelve voice-specializing SLPs who spoke with a General American English (GAE) accent rated vocal percepts of 28 speakers with a foreign language accent and 28 with a GAE accent, all of whom had been diagnosed with a voice disorder. Speaker groups were matched based on sex, age, and mean smoothed cepstral peak prominence. Four linear mixed-effects models assessed the impact of a foreign language accent on expert auditory-perceptual ratings of the overall severity of dysphonia, roughness, breathiness, and strain.

RESULTS

The twelve raters demonstrated good inter- and intra-rater reliability (ICC[3, k] = .89; mean ICC = .89). The linear mixed-effects models revealed no significant impact of foreign language accent on ratings of overall severity of dysphonia, roughness, breathiness, or strain.

CONCLUSION

Despite the possibility of increased listener effort and bias, foreign language accent incongruence had no effect on expert listeners' auditory-perceptual evaluations for dysphonic speakers. Findings support the use of auditory-perceptual evaluations for voice disorders across sociolinguistically diverse populations.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2272-2276, 2024.

Adultification: risk factors, harmful effects and implications for nursing practice

Adultification, whereby children and young people are perceived as older or more mature than they actually are, disproportionately affects those from minority ethnic backgrounds. It can also occur in other contexts, for example when children and young people are placed in a position of adult responsibility. Nurses have a duty to support and protect children and young people, which includes protecting them from adultification and the negative effects it can have on health and well-being. This article discusses strategies nurses can use to prevent adultification - such as developing awareness, avoiding adultifying language and listening to children and young people - and actions to take when suspecting adultification from colleagues.

Smartphone-Based Virtual and Augmented Reality Implicit Association Training (VARIAT) for Reducing Implicit Biases Toward Patients Among Health Care Providers: App Development and Pilot Testing

Background

Implicit bias is as prevalent among health care professionals as among the wider population and is significantly associated with lower health care quality.

Objective

The study goal was to develop and evaluate the preliminary efficacy of an innovative mobile app, VARIAT (Virtual and Augmented Reality Implicit Association Training), to reduce implicit biases among Medicaid providers.

Methods

An interdisciplinary team developed 2 interactive case-based training modules for Medicaid providers focused on implicit bias related to race and socioeconomic status (SES) and sexual orientation and gender identity (SOGI), respectively. The simulations combine experiential learning, facilitated debriefing, and game-based educational strategies. Medicaid providers (n=18) participated in this pilot study. Outcomes were measured on 3 domains: training reactions, affective knowledge, and skill-based knowledge related to implicit biases in race/SES or SOGI.

Results

Participants reported high relevance of training to their job for both the race/SES module (mean score 4.75, SD 0.45) and SOGI module (mean score 4.67, SD 0.50). Significant improvement in skill-based knowledge for minimizing health disparities for lesbian, gay, bisexual, transgender, and queer patients was found after training (Cohen d=0.72; 95% CI -1.38 to -0.04).

Conclusions

This study developed an innovative smartphone-based implicit bias training program for Medicaid providers and conducted a pilot evaluation on the user experience and preliminary efficacy. Preliminary evidence showed positive satisfaction and preliminary efficacy of the intervention.

A Systematic Review of the Effects of Provider Bias on Health in Youth and Young Adults with Type 1 Diabetes

PURPOSE OF REVIEW

Although pervasive inequities in the health outcomes of youth and young adults with type 1 diabetes (T1D) exist, the role of provider bias in these inequities is not well-understood. The purpose of this review is to synthesize evidence from existing studies on the associations between patient characteristics, provider bias, and patient health.

RECENT FINDINGS

Fourteen articles were included. Determining the extent of the effects of provider bias on patient health is limited by a lack of consensus on its definition. Experiences of provider bias (e.g., shaming, criticism) negatively affects self-esteem, relationships with medical providers, and depressive symptoms. Provider bias also impacts diabetes technology recommendations, insulin regimen intensity, and risk for life-threatening T1D complications. Future studies are needed to develop questionnaires and interviews that better account for diverse experiences and interpretations of bias in T1D healthcare. More research is also needed to investigate mitigating factors to reduce provider bias as a way to improve psychological and physical health in individuals with T1D.

Racial bias in perceptions of children's pain

Across eight experiments, we investigated whether adult perceivers (both lay perceivers and elementary school teachers) evaluate children's pain differently depending on the child's race. We found evidence that adults varying in racial and ethnic identities (but primarily White) believed 4- to 6-year-old Black children felt less pain than 4- to 6-year-old White children (Experiments 1-7), and this effect was not moderated by child sex (Experiments 6-7). We also examined perceptions of life hardship as a mediator of this race-to-pain effect, finding that adults evaluated Black children as having lived harder lives and thus as feeling less pain than White children (Experiments 1-3). Finally, we examined downstream consequences for hypothetical treatment recommendations among samples of both lay perceivers and elementary school teachers. We found that adults' perceptions of pain sensitivity were linked with hypothetical pain treatment decisions (Experiments 5a-7). Thus, we consistently observed that adults' race-based pain stereotypes biased evaluations of 4- to 6-year-old children's pain and may influence pain care. This racial bias in evaluations of young children's pain has implications for psychological theory and equitable treatment of children's pain. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Triage Accuracy in Pediatrics Using the Emergency Severity Index

INTRODUCTION

Although the Emergency Severity Index is the most widely used tool in the United States to prioritize care for patients who seek emergency care, including children, there are significant deficiencies in the tool's performance. Inaccurate triage has been associated with delayed treatment, unnecessary diagnostic testing, and bias in clinical care. We evaluated the accuracy of the Emergency Severity Index to stratify patient priority based on predicted resource utilization in pediatric emergency department patients and identified covariates influencing performance.

METHODS

This cross-sectional, retrospective study used a data platform that links clinical and research data sets from a single freestanding pediatric hospital in the United States. Chi-square analysis was used to describes rates of over- and undertriage. Mixed effects ordinal logistic regression identified associations between Emergency Severity Index categories assigned at triage and key emergency department resources using discrete data elements and natural language processing of text notes.

RESULTS

We analyzed 304,422 emergency department visits by 153,984 unique individuals in the final analysis; 80% of visits were triaged as lower acuity Emergency Severity Index levels 3 to 5, with the most common level being Emergency Severity Index 4 (43%). Emergency department visits scored Emergency Severity Index levels 3 and 4 were triaged accurately 46% and 38%, respectively. We noted racial differences in overall triage accuracy.

DISCUSSION

Although the plurality of patients was scored as Emergency Severity Index 4, 50% were mistriaged, and there were disparities based on race indicating Emergency Severity Index mistriages pediatric patients. Further study is needed to elucidate the application of the Emergency Severity Indices in pediatrics using a multicenter emergency department population with diverse clinical and demographic characteristics.

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.

Exploring Referral and Service Utilization Patterns Within an Outpatient Interdisciplinary Pediatric Chronic Pain Program

Purpose

We examine referral sources and clinical characteristics for youth presenting to an outpatient interdisciplinary pediatric chronic pain program.

Patients and Methods

Referral data were extracted from the electronic health record. PROMIS Pediatric Anxiety and Pain Interference Scales were administered at an initial evaluation visit.

Results

The program received 1488 referrals between 2016 and 2019, representing 1338 patients, with increasing volume of referrals over time. Referrals were primarily from orthopedics (19.6%), physical medicine and rehabilitation (18.8%), neurology (14.4%), and rheumatology (12.6%). Patients referred were primarily female (75.4%), White (80.1%), English-speaking (98.4%) adolescents (median=15.0 years). Of those referred, 732 (54.7%) attended an interdisciplinary evaluation (ie, with ≥2 disciplines). Adolescent anxiety was within the expected range by self-report (N=327, MT-score=55.67) and parent proxy-report (N=354, MT-score=57.70). Pain interference was moderately elevated by self-report (N=323, MT-score=61.52) and parent proxy-report (N=356, MT-score=64.02). There were no differences between patients referred who attended versus did not attend an interdisciplinary evaluation based on age, sex, ethnicity, or language. A smaller than expected proportion of referred Black patients (44%, P=0.02) and patients referred from orthopedics (40%) or pulmonology (11%) attended an evaluation, whereas a larger than expected proportion of those referred from physical medicine and rehabilitation (78%) were evaluated (P<0.001).

Conclusion

Results highlight the demand for outpatient interdisciplinary pediatric chronic pain treatment. Findings can inform decisions related to staffing and service design for pediatric hospitals that aim to establish or grow outpatient pediatric chronic pain programs.

Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence

Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.

A scoping review of research on potential impact of implicit bias in healthcare settings for children with acquired brain injuries

PURPOSE/OBJECTIVE

Acquired brain injury (ABI) is a leading cause of disability in children and adolescents. Implicit biases within pediatric ABI healthcare settings may exert negative effects on clinical interactions and medical decision-making processes. This study aimed to conduct a scoping review of current research that examines the potential impact of implicit biases in such healthcare settings for children with ABI.

RESEARCH METHOD/DESIGN

Following PRISMA-ScR guidelines, a search among five databases (CINAHL, Cochrane CENTRAL, PubMed, PsycArticles, and PsycInfo) was conducted, followed by abstract/full-text screening and data extraction. Main characteristics of the included studies, including research design, relevance to implicit biases, and public health impact were synthesized. The risk of bias of included studies was assessed.

RESULTS

Out of the 203 articles returned from the literature search, a total of three studies met the inclusion criteria for the present review. All studies examined the relevance of racial/ethnic biases for evaluating abusive head trauma or nonaccidental trauma. The included studies had an overall unclear to low risk of biases.

CONCLUSIONS/IMPLICATIONS

This scoping review identified scarce but emerging evidence of the presence and detrimental impact of potential implicit biases on the access and quality of care received by children with ABI. More research is needed to examine the causes, process mechanisms, and consequences of implicit biases in pediatric ABI healthcare settings. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Implicit racial bias among dental hygienists practicing in the United States

PURPOSE

Provider bias has been shown to be a contributing factor to racial and ethnic disparities observed in health care settings. The purpose of this study was to examine implicit racial bias among dental hygienists.

METHODS

A convenience sample of licensed and practicing dental hygienists within the United States was recruited through email and national dental hygiene social media groups via snowball sampling. A two-part survey design was used for data collection. Participants completed a 10-item demographic survey through an online platform and were then routed to the Race Implicit Association Test (IAT). Descriptive statistics and linear regression analyses were used to compare demographic data and implicit racial preference scores (d-scores).

RESULTS

Data from 404 licensed dental hygienists were included in this study. Over two-thirds (67.8%) of participants showed a preference for European Americans over African Americans. A significant difference was found between implicit racial preference scores and participant age (Estimate: 0.01, 95% CI: 0.00, 0.01), years worked comparing <5 years to 21 or more years (Estimate: 0.19, 95% CI: -0.30, -0.09) and race comparing non-White to White (Estimate: -0.17, 95% CI: -0.27, -0.07). No difference was found with task order, previous Race IAT experience, or previous self-reported implicit bias training.

CONCLUSIONS

Findings suggest that dental hygienists may harbor implicit racial preferences for European Americans over African Americans. Non-White participants had more positive implicit preferences toward African Americans compared to White participants. Further research is needed to determine the extent to which implicit racial biases contribute to disparities in oral health.