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Nash KA, Tolliver DG, Foster AA. Accountability to Quality and Equity of Care for Children With Acute Agitation in the Emergency Department. Hosp Pediatr 2024; 14:390-393. [PMID: 38618650 DOI: 10.1542/hpeds.2024-007776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Katherine A Nash
- Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Destiny G Tolliver
- Department of Pediatrics, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Ashley A Foster
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California
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Puissant MM, Agarwal I, Scharnetzki E, Cutler A, Gunnell H, Strout TD. Racial differences in triage assessment at rural vs urban Maine emergency departments. Intern Emerg Med 2024:10.1007/s11739-024-03560-4. [PMID: 38598085 DOI: 10.1007/s11739-024-03560-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 02/06/2024] [Indexed: 04/11/2024]
Abstract
Data continue to accumulate demonstrating that those belonging to racialized groups face implicit bias in the emergency care delivery system across many indices, including triage assessment. The Emergency Severity Index (ESI) was developed and widely implemented across the US to improve the objectivity of triage assessment and prioritization of care delivery; however, research continues to support the presence of subjective bias in triage assessment. We sought to assess the relationship between perceived race and/or need for translator and assigned ESI score and whether this was impacted by hospital geography. We performed retrospective EMR-based review of patients presenting to urban and rural emergency departments of a health system in Maine with one of the top ten most common chief complaints (CC) across a 5-year period, excluding psychiatric CCs. We used multivariable regression to analyze the relationships between perceived race, need for translator, and gender with ESI score, wait time, and hallway bed assignments. We found that patients perceived as non-white were more likely to receive lower acuity ESI scores and have longer wait times as compared to patients perceived as white. Patients perceived as female were more likely to receive lower acuity scores and wait longer to be seen than patients perceived as male. The need for an interpreter was associated with increased wait times but not significantly associated with ESI score. After stratification by hospital geography, evidence of subjective bias was limited to urban emergency departments and was not evident in rural emergency departments. Further investigation of subjective bias in emergency departments in Maine, particularly in urban settings, is warranted.
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Affiliation(s)
- Madeleine M Puissant
- Department of Emergency Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA.
- MHIR-CIPHR, 1 Riverfront Plaza, Westbrook, ME, 04092, USA.
- Tufts University School of Medicine, Boston, MA, USA.
| | - Isha Agarwal
- Department of Emergency Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
- MHIR-CIPHR, 1 Riverfront Plaza, Westbrook, ME, 04092, USA
- Tufts University School of Medicine, Boston, MA, USA
| | | | - Anya Cutler
- MHIR-CIPHR, 1 Riverfront Plaza, Westbrook, ME, 04092, USA
| | - Hadley Gunnell
- Department of Emergency Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Tania D Strout
- Department of Emergency Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
- Tufts University School of Medicine, Boston, MA, USA
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Gutman CK, Fernandez R, McFarlane A, Krajewski JMT, Casey Lion K, Aronson PL, Bylund CL, Holmes S, Fisher CL. "Let us take care of the medicine": A qualitative analysis of physician communication when caring for febrile infants. Acad Pediatr 2024:S1876-2859(24)00070-6. [PMID: 38458491 DOI: 10.1016/j.acap.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Guidelines for the management of febrile infants emphasize patient-centered communication. Although patient-centeredness is central to high-quality healthcare, biases may impact physicians' patient-centeredness. We aimed to 1) identify physicians' assumptions that inform their communication with parents of febrile infants and 2) examine physicians' perceptions of bias. METHODS We recruited physicians from three academic pediatric emergency departments (EDs) for semi-structured interviews. We applied a constant comparative method approach to conduct a thematic analysis of interview transcripts. Two coders followed several analytical steps: 1) discovery of concepts and code assignment, 2) identification of themes by grouping concepts, 3) axial coding to identify thematic properties, and 4) identifying exemplar excerpts for rich description. Thematic saturation was based on repetition, recurrence, and forcefulness. RESULTS Fourteen physicians participated. Participants described making assumptions regarding three areas: 1) the parent's affect, 2) the parent's social capacity, and 3) the physician's own role in the parent-physician interaction. Thematic properties highlighted the importance of the physician's assumptions in guiding communication and decision-making. Participants acknowledged an awareness of bias, and specifically noted that language bias influenced the assumptions that informed their communication. CONCLUSIONS ED physicians described subjective assumptions about parents that informed their approach to communication when caring for febrile infants. Given the emphasis on patient-centered communication in febrile infant guidelines, future efforts are necessary to understand how assumptions are influenced by biases, the effect of such behaviors on health inequities, and how to combat this. WHAT'S NEW Physician communication drives health outcomes. In this qualitative investigation, physicians described making assumptions about parents, based on subjective assessments, which informed their communication and decision-making. This represents a step towards understanding how biases inform communication and result in health inequity.
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Affiliation(s)
- Colleen K Gutman
- Departments of Emergency Medicine and Pediatrics, University of Florida College of Medicine, Gainesville, FL.
| | - Rosemarie Fernandez
- Department of Emergency Medicine and Center for Experiential Learning and Simulation, University of Florida College of Medicine, Gainesville, FL
| | - Antionette McFarlane
- Department of Emergency Medicine and Center for Experiential Learning and Simulation, University of Florida College of Medicine, Gainesville, FL
| | | | - K Casey Lion
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Carma L Bylund
- Department of Health Outcomes & Biomedical Informatics, University of Florida College of Medicine, Gainesville, Fl
| | - Sherita Holmes
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Carla L Fisher
- Departments of Pediatrics and Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT
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Parikh K, Hall M, Tieder JS, Dixon G, Ward MC, Hinds PS, Goyal MK, Rangel SJ, Flores G, Kaiser SV. Disparities in Racial, Ethnic, and Payer Groups for Pediatric Safety Events in US Hospitals. Pediatrics 2024; 153:e2023063714. [PMID: 38343330 DOI: 10.1542/peds.2023-063714] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Health care disparities are pervasive, but little is known about disparities in pediatric safety. We analyzed a national sample of hospitalizations to identify disparities in safety events. METHODS In this population-based, retrospective cohort study of the 2019 Kids' Inpatient Database, independent variables were race, ethnicity, and payer. Outcomes were Agency for Healthcare Research and Quality pediatric safety indicators (PDIs). Risk-adjusted odds ratios were calculated using white and private payer reference groups. Differences by payer were evaluated by stratifying race and ethnicity. RESULTS Race and ethnicity of the 5 243 750 discharged patients were white, 46%; Hispanic, 19%; Black, 15%; missing, 8%; other race/multiracial, 7%, Asian American/Pacific Islander, 5%; and Native American, 1%. PDI rates (per 10 000 discharges) were 331.4 for neonatal blood stream infection, 267.5 for postoperative respiratory failure, 114.9 for postoperative sepsis, 29.5 for postoperative hemorrhage/hematoma, 5.6 for central-line blood stream infection, 3.5 for accidental puncture/laceration, and 0.7 for iatrogenic pneumothorax. Compared with white patients, Black and Hispanic patients had significantly greater odds in 5 of 7 PDIs; the largest disparities occurred in postoperative sepsis (adjusted odds ratio, 1.55 [1.38-1.73]) for Black patients and postoperative respiratory failure (adjusted odds ratio, 1.34 [1.21-1.49]) for Hispanic patients. Compared with privately insured patients, Medicaid-covered patients had significantly greater odds in 4 of 7 PDIs; the largest disparity occurred in postoperative sepsis (adjusted odds ratios, 1.45 [1.33-1.59]). Stratified analyses demonstrated persistent disparities by race and ethnicity, even among privately insured children. CONCLUSIONS Disparities in safety events were identified for Black and Hispanic children, indicating a need for targeted interventions to improve patient safety in the hospital.
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Affiliation(s)
- Kavita Parikh
- Children's National Hospital, Washington, District of Columbia
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | | | - Gabrina Dixon
- Children's National Hospital, Washington, District of Columbia
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Maranda C Ward
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Pamela S Hinds
- Children's National Hospital, Washington, District of Columbia
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Monika K Goyal
- Children's National Hospital, Washington, District of Columbia
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | | | - Glenn Flores
- Department of Pediatrics, University of Miami Miller School of Medicine, and Holtz Children's Hospital, Jackson Health System, Miami, Florida
| | - Sunitha V Kaiser
- University of California, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California
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Patel MD, Lin P, Cheng Q, Argon NT, Evans CS, Linthicum B, Liu Y, Mehrotra A, Murphy L, Ziya S. Patient sex, racial and ethnic disparities in emergency department triage: A multi-site retrospective study. Am J Emerg Med 2024; 76:29-35. [PMID: 37980725 DOI: 10.1016/j.ajem.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/30/2023] [Accepted: 11/07/2023] [Indexed: 11/21/2023] Open
Abstract
OBJECTIVES There is limited evidence on sex, racial, and ethnic disparities in Emergency Department (ED) triage across diverse settings. We evaluated differences in the assignment of Emergency Severity Index (ESI) by patient sex and race/ethnicity, accounting for age, clinical factors, and ED operating conditions. METHODS We conducted a multi-site retrospective study of adult patients presenting to high-volume EDs from January 2019-February 2020. Patient-level data were obtained and analyzed from three EDs (academic, metropolitan community, and rural community) affiliated with a large health system in the Southeastern United States. For the study outcome, ESI levels were grouped into three categories: 1-2 (highest acuity), 3, and 4-5 (lowest acuity). Multinomial logistic regression was used to compare ESI categories by patient race/ethnicity and sex jointly (referent = White males), adjusted for patient age, insurance status, ED arrival mode, chief complaint category, comorbidity score, time of day, day of week, and average ED wait time. RESULTS We identified 186,840 eligible ED visits with 56,417 from the academic ED, 69,698 from the metropolitan community ED, and 60,725 from the rural community ED. Patient cohorts between EDs varied by patient age, race/ethnicity, and insurance status. The majority of patients were assigned ESI 3 in the academic and metropolitan community EDs (61% and 62%, respectively) whereas 47% were assigned ESI 3 in the rural community ED. In adjusted analyses, White females were less likely to be assigned ESI 1-2 compared to White males although both groups were roughly comparable in the assignment of ESI 4-5. Non-White and Hispanic females were generally least likely to be assigned ESI 1-2 in all EDs. Interactions between ED wait time and race/ethnicity-sex were not statistically significant. CONCLUSIONS This retrospective study of adult ED patients revealed sex and race/ethnicity-based differences in ESI assignment, after accounting for age, clinical factors, and ED operating conditions. These disparities persisted across three different large EDs, highlighting the need for ongoing research to address inequities in ED triage decision-making and associated patient-centered outcomes.
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Affiliation(s)
- Mehul D Patel
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, NC, USA.
| | - Peter Lin
- Department of Statistics and Operations Research, University of North Carolina at Chapel Hill, NC, USA
| | - Qian Cheng
- Department of Statistics and Operations Research, University of North Carolina at Chapel Hill, NC, USA
| | - Nilay T Argon
- Department of Statistics and Operations Research, University of North Carolina at Chapel Hill, NC, USA
| | - Christopher S Evans
- Information Services, ECU Health, Greenville, NC, USA; Department of Emergency Medicine, East Carolina University, Greenville, NC, USA
| | - Benjamin Linthicum
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Yufeng Liu
- Department of Statistics and Operations Research, University of North Carolina at Chapel Hill, NC, USA; Department of Genetics, Department of Biostatistics, University of North Carolina at Chapel Hill, NC, USA
| | - Abhi Mehrotra
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Laura Murphy
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Serhan Ziya
- Department of Statistics and Operations Research, University of North Carolina at Chapel Hill, NC, USA
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Haimovich AD, Taylor RA, Chang-Sing E, Brashear T, Cramer LD, Lopez K, Wong AH. Disparities Associated With Electronic Behavioral Alerts for Safety and Violence Concerns in the Emergency Department. Ann Emerg Med 2024; 83:100-107. [PMID: 37269262 PMCID: PMC10689576 DOI: 10.1016/j.annemergmed.2023.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/12/2023] [Accepted: 04/05/2023] [Indexed: 06/05/2023]
Abstract
STUDY OBJECTIVE Although electronic behavioral alerts are placed as an alert flag in the electronic health record to notify staff of previous behavioral and/or violent incidents in emergency departments (EDs), they have the potential to reinforce negative perceptions of patients and contribute to bias. We provide characterization of ED electronic behavioral alerts using electronic health record data across a large, regional health care system. METHODS We conducted a retrospective cross-sectional study of adult patients presenting to 10 adult EDs within a Northeastern United States health care system from 2013 to 2022. Electronic behavioral alerts were manually screened for safety concerns and then categorized by the type of concern. In our patient-level analyses, we included patient data at the time of the first ED visit where an electronic behavioral alert was triggered or, if a patient had no electronic behavioral alerts, the earliest visit in the study period. We performed a mixed-effects regression analysis to identify patient-level risk factors associated with safety-related electronic behavioral alert deployment. RESULTS Of the 2,932,870 ED visits, 6,775 (0.2%) had associated electronic behavioral alerts across 789 unique patients and 1,364 unique electronic behavioral alerts. Of the encounters with electronic behavioral alerts, 5,945 (88%) were adjudicated as having a safety concern involving 653 patients. In our patient-level analysis, the median age for patients with safety-related electronic behavioral alerts was 44 years (interquartile range 33 to 55 years), 66% were men, and 37% were Black. Visits with safety-related electronic behavioral alerts had higher rates of discontinuance of care (7.8% vs 1.5% with no alert; P<.001) as defined by the patient-directed discharge, left-without-being-seen, or elopement-type dispositions. The most common topics in the electronic behavioral alerts were physical (41%) or verbal (36%) incidents with staff or other patients. In the mixed-effects logistic analysis, Black non-Hispanic patients (vs White non-Hispanic patients: adjusted odds ratio 2.60; 95% confidence interval [CI] 2.13 to 3.17), aged younger than 45 (vs aged 45-64 years: adjusted odds ratio 1.41; 95% CI 1.17 to 1.70), male (vs female: adjusted odds ratio 2.09; 95% CI 1.76 to 2.49), and publicly insured patients (Medicaid: adjusted odds ratio 6.18; 95% CI 4.58 to 8.36; Medicare: adjusted odds ratio 5.63; 95% CI 3.96 to 8.00 vs commercial) were associated with a higher risk of a patient having at least 1 safety-related electronic behavioral alert deployment during the study period. CONCLUSION In our analysis, younger, Black non-Hispanic, publicly insured, and male patients were at a higher risk of having an ED electronic behavioral alert. Although our study is not designed to reflect causality, electronic behavioral alerts may disproportionately affect care delivery and medical decisions for historically marginalized populations presenting to the ED, contribute to structural racism, and perpetuate systemic inequities.
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Affiliation(s)
- Adrian D Haimovich
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - R Andrew Taylor
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | - Erika Chang-Sing
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Taylor Brashear
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Laura D Cramer
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT
| | - Kevin Lopez
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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Morzenti OA, Brennhofer SA, Calley KH, Stephenson MC. Implicit racial bias among dental hygienists practicing in the United States. Int J Dent Hyg 2024; 22:244-250. [PMID: 37746722 DOI: 10.1111/idh.12766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/26/2023]
Abstract
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.
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Affiliation(s)
- Olivia A Morzenti
- Prevea Health, Green Bay, Wisconsin, USA
- Department of Dental Hygiene, Idaho State University, Pocatello, Idaho, USA
| | | | - Kristin H Calley
- Department of Dental Hygiene, Idaho State University, Pocatello, Idaho, USA
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Agboola IK, Rosenberg A, Robinson L, Brashear TK, Eixenberger C, Shah D, Pavlo AJ, Im DD, Ray JM, Coupet E, Wong AH. A Qualitative Study of Racial, Ethnic, and Cultural Experiences of Minority Clinicians During Agitation Care in the Emergency Department. Ann Emerg Med 2024; 83:108-119. [PMID: 37855791 PMCID: PMC10843036 DOI: 10.1016/j.annemergmed.2023.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/31/2023] [Accepted: 09/18/2023] [Indexed: 10/20/2023]
Abstract
STUDY OBJECTIVE Racial and ethnic bias in health care has been documented at structural, organizational, and clinical levels, impacting emergency care, including agitation management in the emergency department (ED). Little is known about the experiences of racial and ethnic minority ED clinicians caring for racial and ethnic minority groups, especially during their agitated state. The objective of this study was to explore the lived experiences of racial and ethnic minority ED clinicians who have treated patients with agitation in the ED. METHODS We performed semistructured individual interviews of Black, Latino, and multiracial clinicians who worked at 1 of 3 EDs from an urban quaternary care medical center in the Northeast United States between August 2020 and June 2022. We performed thematic analysis through open coding of initial transcripts and identifying additional codes through sequential iterative rounds of group discussion. Once the codebook was finalized and applied to all transcripts, the team identified key themes and subthemes. RESULTS Of the 27 participants interviewed, 14 (52%) identified as Black, 9 (33%) identified as Hispanic/Latino, and 4 (15%) identified as multiracial and/or other race and ethnicity. Three primary themes emerged from racial and ethnic minority clinician experiences of managing agitation: witness of perceived bias during clinical interactions with patients of color who bear racialized presumptions of agitation, moral injury and added workload to address perceived biased agitation management practices while facing discrimination in the workplace, and natural advocacy and allyship for agitated patients of color based on a shared identity and life experience. CONCLUSIONS Our study found that through their shared minority status, racial and ethnic minority clinicians had a unique vantage point to observe perceived bias in the management of agitation in minority patients. Although they faced added challenges as racial and ethnic minority clinicians, their allyship offered potential mitigation strategies for addressing disparities in caring for an underserved and historically marginalized patient population.
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Affiliation(s)
- Isaac K Agboola
- Department of Emergency Medicine, NorthShore University Health System, Evanston, Illinois; Department of Emergency Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois; Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alana Rosenberg
- SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, Connecticut
| | - Leah Robinson
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Taylor K Brashear
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Dhruvil Shah
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Anthony J Pavlo
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Dana D Im
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jessica M Ray
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida
| | - Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut.
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Ruedinger E, Evans YN, Pham DQ, Hooper L. Just-in-Time Strategies to Reduce the Effect of Interviewer Bias During Trainee Recruitment. Acad Pediatr 2024:S1876-2859(24)00020-2. [PMID: 38280713 DOI: 10.1016/j.acap.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 01/29/2024]
Abstract
Bias impacts all aspects of medical trainee applications, from grades to narrative reviews. Interviews provide an avenue to become acquainted with applicants beyond their written application, but even the most egalitarian interviewers are subject to implicit biases, including those who hold marginalized identities themselves. Simply building awareness around implicit bias is inadequate to reduce the effect. Here, 5 evidence-informed strategies are presented that can be implemented by faculty on-the-spot to mitigate the impact of implicit bias during the short interview interaction: individuation, mindfulness, perspective taking, stereotype replacement, and counter-stereotypic imaging. These strategies can be used by individual interviewers as one component of a comprehensive plan including institutional changes to promote more equitable recruitment processes.
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Affiliation(s)
- Emily Ruedinger
- Department of Pediatrics (E Ruedinger), University of Wisconsin School of Medicine and Public Health, Madison, Wis.
| | - Yolanda N Evans
- Department of Pediatrics (YN Evans), University of Washington School of Medicine, Seattle, Wash.
| | - Do-Quyen Pham
- Division of School Health and Maternal and Child Health (D-Q Pham), Fairfax County Health Department, Fairfax, Va.
| | - Laura Hooper
- Division of Adolescent Medicine (L Hooper), Indiana University, Indianapolis, Ind.
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Moyal-Smith R, Barnett DJ, Toner ES, Marsteller JA, Yuan CT. Embedding Equity into the Hospital Incident Command System: A Narrative Review. Jt Comm J Qual Patient Saf 2024; 50:49-58. [PMID: 38044219 DOI: 10.1016/j.jcjq.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 10/21/2023] [Accepted: 10/23/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Disasters exacerbate health inequities, with historically marginalized populations experiencing unjust differences in health care access and outcomes. Health systems plan and respond to disasters using the Hospital Incident Command System (HICS), an organizational structure that centralizes communication and decision-making. The HICS does not have an equity role or considerations built into its standard structure. The authors conducted a narrative review to identify and summarize approaches to embedding equity into the HICS. METHODS The peer-reviewed (PubMed, SCOPUS) and gray literature was searched for articles from high-income countries that referenced the HICS or Incident Command System (ICS) and equity, disparities, or populations that experience inequities in disasters. The primary focus of the search strategy was health care, but the research also included governmental and public health system articles. Two authors used inductive thematic analysis to assess commonalities and refined the themes based on feedback from all authors. RESULTS The database search identified 479 unique abstracts; 76 articles underwent full-text review, and 11 were included in the final analysis. The authors found 5 articles through cited reference searching and 13 from the gray literature search, which included websites, organizations, and non-indexed journal articles. Three themes from the articles were identified: including equity specialists in the HICS, modifying systems to promote equity, and sensitivity to the local community. CONCLUSION Several efforts to embed equity into the HICS and disaster preparedness and response were discovered. This review provides practical strategies health system leaders can include in their HICS and emergency preparedness plans to promote equity in their disaster response.
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Pino EC, Gonzalez F, Nelson KP, Jaiprasert S, Lopez GM. Disparities in use of physical restraints at an urban, minority-serving hospital emergency department. Acad Emerg Med 2024; 31:6-17. [PMID: 37597262 DOI: 10.1111/acem.14792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Recent reports have identified associations between patient race and ethnicity and use of physical restraint while receiving care in the emergency department (ED). However, no study has assessed this relationship in hospitals primarily treating patients of color and underserved populations. The primary objective of this study was to evaluate the association between race/ethnicity and the use of restraints in an ED population at a minority-serving, safety-net institution. METHODS For this cross-sectional study, chart review identified all adult patients presenting to the Boston Medical Center ED between January 2018 and April 2021. Generalized estimating equation logistic regression modeling was conducted to evaluate associations between race and use of restraints. RESULTS Of 348,384 ED visits (22.9% White, 46.7% Black, 23.1% Hispanic), 1852 (0.5%) had an associated physical restraint order. Multivariable models showed significant interactions (p = 0.02) between race/ethnicity, behavioral health diagnosis, and sex on the primary outcome of physical restraint. Stratified analysis revealed that among patients with no behavioral health diagnoses, Black (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.34-0.72, p = 0.0003) and Hispanic (OR 0.35, 95% CI 0.20-0.63, p = 0.0004) patients had lower odds of restraint than White patients. Among female patients with a mental health and/or substance use disorder diagnosis, Black (OR 1.95, 95% CI 1.49-2.54, p < 0.0001) and Hispanic (OR 2.13, 95% CI 1.49-3.03, p < 0.0001) patients had higher odds of restraint than White patients. Similar trends were observed for Black male patients (OR 1.60, 95% CI 1.34-1.91, p < 0.0001) but not for Hispanic male patients (OR 0.96, 95% CI 0.73-1.26, p = 0.77) with behavioral health diagnoses who had similar odds of restraint to White patients. Additional factors associated with physical restraint include younger age, public or lack of insurance, and ED visits during the pandemic. CONCLUSIONS Racial disparities exist in restraint utilization at this minority-serving safety-net hospital; however, these disparities are modified by sex and by behavioral health diagnoses. The reasons for these disparities may be multifactorial and warrant further investigation.
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Affiliation(s)
- Elizabeth C Pino
- Department of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Felisha Gonzalez
- Department of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Kerrie P Nelson
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sorraya Jaiprasert
- Department of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Gina M Lopez
- Department of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
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12
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Norotsky RL, Dahl KL, Cocroft S, Sauder C, Tracy LF, Stepp CE. Does Implicit Racial Bias Affect Auditory-Perceptual Evaluations of Dysphonic Voices? J Voice 2023:S0892-1997(23)00383-1. [PMID: 38065808 DOI: 10.1016/j.jvoice.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 01/07/2024]
Abstract
PURPOSE The purpose of this study was to understand the role of implicit racial bias in auditory-perceptual evaluations of dysphonic voices by determining if a biasing effect exists for novice listeners in their auditory-perceptual ratings of Black and White speakers. METHOD Thirty speech-language pathology graduate students at Boston University listened to audio files of 20 Black speakers and 20 White speakers of General American English with voice disorders. Listeners rated the overall severity of dysphonia of each voice heard using a 100-unit visual analog scale and completed the Harvard Implicit Association Test (IAT) to measure their implicit racial bias. RESULTS Both Black and White speakers were rated as less severely dysphonic when their race was labeled as Black. No significant relationship was found between Harvard IAT scores and differences in severity ratings by race labeling condition. CONCLUSIONS These findings suggest a minimizing bias in the evaluation of dysphonia for Black patients with voice disorders. These results contribute to the understanding of how a patient's race may impact their visit with a clinician. Further research is needed to determine the most effective interventions for implicit bias retraining and the additional ways that implicit racial bias impacts comprehensive voice evaluations.
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Affiliation(s)
- Rachel L Norotsky
- Department of Speech, Language, and Hearing Sciences, Boston University, Boston, Massachusetts.
| | - Kimberly L Dahl
- Department of Speech, Language, and Hearing Sciences, Boston University, Boston, Massachusetts
| | - Sarah Cocroft
- Department of Speech, Language, and Hearing Sciences, Boston University, Boston, Massachusetts
| | - Cara Sauder
- Department of Speech and Hearing Sciences, University of Washington, Seattle, Washington
| | - Lauren F Tracy
- Department of Speech, Language, and Hearing Sciences, Boston University, Boston, Massachusetts; Department of Otolaryngology - Head and Neck Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Cara E Stepp
- Department of Speech, Language, and Hearing Sciences, Boston University, Boston, Massachusetts; Department of Otolaryngology - Head and Neck Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts; Department of Biomedical Engineering, Boston University, Boston, Massachusetts
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13
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Rickert J. On Patient Safety: When Doctors Strike. Clin Orthop Relat Res 2023; 481:2325-2327. [PMID: 37909912 PMCID: PMC10642862 DOI: 10.1097/corr.0000000000002917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023]
Affiliation(s)
- James Rickert
- President, The Society for Patient Centered Orthopedics, Bloomington, IN, USA
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14
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Affiliation(s)
- Destiny G Tolliver
- Boston University Chobanian & Avedisian School of Medicine, Department of Pediatrics, Boston, Massachusetts
| | - Jeffrey G Edwards
- Boston Combined Residency Program in Pediatrics, Boston Medical Center and Boston Children's Hospital, Boston, Massachusetts
| | - Arjun K Venkatesh
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
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15
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Macias-Konstantopoulos WL, Collins KA, Diaz R, Duber HC, Edwards CD, Hsu AP, Ranney ML, Riviello RJ, Wettstein ZS, Sachs CJ. Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity. West J Emerg Med 2023; 24:906-918. [PMID: 37788031 PMCID: PMC10527840 DOI: 10.5811/westjem.58408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 04/17/2023] [Accepted: 05/24/2023] [Indexed: 10/04/2023] Open
Abstract
An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.
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Affiliation(s)
- Wendy L Macias-Konstantopoulos
- Center for Social Justice and Health Equity, Department of Emergency Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | | | - Rosemarie Diaz
- University of California-Los Angeles, Department of Emergency Medicine, Los Angeles, California
| | - Herbert C Duber
- University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
- Washington State Department of Health, Tumwater, Washington
| | - Courtney D Edwards
- Samford University, Moffett & Sanders School of Nursing, Birmingham, Alabama
| | - Antony P Hsu
- Trinity Health Ann Arbor Hospital, Department of Emergency Medicine, Ypsilanti, Michigan
| | - Megan L Ranney
- Yale University, Yale School of Public Health, New Haven, Connecticut
| | - Ralph J Riviello
- University of Texas Health San Antonio, Department of Emergency Medicine, San Antonio, Texas
| | - Zachary S Wettstein
- University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
| | - Carolyn J Sachs
- Ronald Reagan-UCLA Medical Center and David Geffen School of Medicine at University of California-Los Angeles, Department of Emergency Medicine, Los Angeles, California
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16
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Kosoko AA, Alford YR, Upplegger KA, Stevens GS. Not Just a Pain: A Medical Simulation Case About Biased Communication and Osteomyelitis in Pediatric Sickle Cell Anemia. MedEdPORTAL 2023; 19:11335. [PMID: 37593566 PMCID: PMC10427742 DOI: 10.15766/mep_2374-8265.11335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 05/01/2023] [Indexed: 08/19/2023]
Abstract
Introduction Biases in communication can be harmful to patient perceptions of care and the medical team's decision-making. Optimal communication must be taught and practiced similarly to the optimal management of the complex medical conditions associated with sickle cell disease (SCD). This simulation is designed to teach about biases, optimizing communication to and about a patient with SCD, and appropriately diagnosing and managing pediatric osteomyelitis as a complication of SCD. Methods We designed and implemented a simulation case targeting emergency medicine residents and fellows to raise awareness about biases associated with SCD care and the complication of osteomyelitis in children with SCD. The case was delivered as a scheduled educational activity. Guided debriefing about optimizing care and communication for this patient population followed the simulation. We measured outcomes based on facilitator field notes and participant evaluations (Likert-scale and open-response questions). Results Forty learners of varying medical practice proficiencies, societal experiences, and demographics participated, with 30 completing the postsimulation feedback survey. A majority (97%) of participants indicated that the experience was useful and would improve their clinical performance. Participants learned from each other's language and communication styles and reflected on their own communication. Discussion Overall, participants found the simulation very useful as a review of the medical diagnosis and management of osteomyelitis in pediatric SCD. Moreover, they were very engaged and interested in the opportunity to learn about communication biases, particularly as these relate to SCD, to optimize their patient care.
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Affiliation(s)
- Adeola A. Kosoko
- Assistant Professor, Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Yakira R. Alford
- Third-Year Resident, Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Karl A. Upplegger
- Pediatric Emergency Medicine Fellow, Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Gowri S. Stevens
- Assistant Professor, Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston
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17
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Meidert U, Dönnges G, Bucher T, Wieber F, Gerber-Grote A. Unconscious Bias among Health Professionals: A Scoping Review. Int J Environ Res Public Health 2023; 20:6569. [PMID: 37623155 PMCID: PMC10454622 DOI: 10.3390/ijerph20166569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Unconscious biases are one of the causes of health disparities. Health professionals have prejudices against patients due to their race, gender, or other factors without their conscious knowledge. This review aimed to provide an overview of research on unconscious bias among health professionals and to investigate the biases that exist in different regions of the world, the health professions that are considered, and the research gaps that still exist. METHODS We conducted a scoping review by systematically searching PubMed/MEDLINE, CINAHL, PsycINFO, PsycARTICLES, and AMED. All records were double-screened and included if they were published between 2011 and 2021. RESULTS A total of 5186 records were found. After removing duplicates (n = 300), screening titles and abstracts (n = 4210), and full-text screening (n = 695), 87 articles from 81 studies remained. Studies originated from North America (n = 60), Europe (n = 13), and the rest of the world (n = 6), and two studies were of global scope. Racial bias was investigated most frequently (n = 46), followed by gender bias (n = 11), weight bias (n = 10), socio-economic status bias (n = 9), and mental illness bias (n = 7). Most of the studies were conducted by physicians (n = 51) and nurses (n = 20). Other health care professionals were rarely included in these studies. CONCLUSIONS Most studies show that health professionals have an implicit bias. Racial biases among physicians and nurses in the USA are well confirmed. Research is missing on other biases from other regions and other health professions.
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Affiliation(s)
- Ursula Meidert
- School of Health Sciences, Zurich University of Applied Sciences, Katharina-Sulzer-Platz 9, 8400 Winterthur, Switzerland; (G.D.); (T.B.); (F.W.); (A.G.-G.)
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18
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Gutman CK, Thompson M, Gonzalez J, Fernandez R. Patient centered or provider centered? The inclusion of social determinants of health in emergency department billing and coding. Acad Emerg Med 2023; 30:882-884. [PMID: 36794328 PMCID: PMC10866376 DOI: 10.1111/acem.14698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 02/17/2023]
Affiliation(s)
- Colleen K Gutman
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Meredith Thompson
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Juan Gonzalez
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Rosemarie Fernandez
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
- Center for Experiential Learning and Simulation, University of Florida College of Medicine, Gainesville, Florida, USA
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19
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Jacobs S, Brar K, Nowak-Wegrzyn A, Louisias M. Why You Should Care About Implicit Bias as an Allergist-Immunologist and Ways We Can Address It. J Allergy Clin Immunol Pract 2023; 11:1718-1724. [PMID: 36972799 DOI: 10.1016/j.jaip.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 02/06/2023] [Accepted: 03/12/2023] [Indexed: 03/29/2023]
Affiliation(s)
- Samantha Jacobs
- Department of Pediatrics, New York University School of Medicine, New York, NY
| | - Kanwaljit Brar
- Allergy and Immunology, Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, NY
| | - Anna Nowak-Wegrzyn
- Allergy and Immunology, Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Division of Immunology, Boston Children's Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
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20
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Moorthy GS, Young RR, Smith MJ, White MJ, Hong H, Kelly MS. Racial Inequities in Sepsis Mortality Among Children in the United States. Pediatr Infect Dis J 2023; 42:361-367. [PMID: 36795560 PMCID: PMC10101919 DOI: 10.1097/inf.0000000000003842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND Racial inequities influence health outcomes in the United States, but their impact on sepsis outcomes among children is understudied. We aimed to evaluate for racial inequities in sepsis mortality using a nationally representative sample of pediatric hospitalizations. METHODS This population-based, retrospective cohort study used the 2006, 2009, 2012 and 2016 Kids' Inpatient Database. Eligible children 1 month to 17 years old were identified using sepsis-related International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision codes. We used modified Poisson regression to evaluate the association between patient race and in-hospital mortality, clustering by hospital and adjusting for age, sex and year. We used Wald tests to assess for modification of associations between race and mortality by sociodemographic factors, geographic region and insurance status. RESULTS Among 38,234 children with sepsis, 2555 (6.7%) died in-hospital. Compared with White children, mortality was higher among Hispanic (adjusted relative risk: 1.09; 95% confidence interval: 1.05-1.14), Asian/Pacific Islander (1.17, 1.08-1.27) and children from other racial minority groups (1.27, 1.19-1.35). Black children had similar mortality to White children overall (1.02, 0.96-1.07), but higher mortality in the South (7.3% vs. 6.4%; P < 0.0001). Hispanic children had higher mortality than White children in the Midwest (6.9% vs. 5.4%; P < 0.0001), while Asian/Pacific Islander children had higher mortality than all other racial categories in the Midwest (12.6%) and South (12.0%). Mortality was higher among uninsured children than among privately insured children (1.24, 1.17-1.31). CONCLUSIONS Risk of in-hospital mortality among children with sepsis in the United States differs by patient race, geographic region and insurance status.
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Affiliation(s)
- Ganga S. Moorthy
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Rebecca R. Young
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Michael J. Smith
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Michelle J. White
- Division of Hospital Medicine, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Hwanhee Hong
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Matthew S. Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
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21
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Hartford EA, Thomas AA, Kerwin O, Usoro E, Yoshida H, Burns B, Rutman LE, Migita R, Bradford M, Akhter S. Toward Improving Patient Equity in a Pediatric Emergency Department: A Framework for Implementation. Ann Emerg Med 2023; 81:385-392. [PMID: 36669917 DOI: 10.1016/j.annemergmed.2022.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 01/20/2023]
Abstract
Disparities in health care delivery and health outcomes for patients in the emergency department (ED) by race, ethnicity, and language for care (REaL) are common and well documented. Addressing inequities from structural racism, implicit bias, and language barriers can be challenging, and there is a lack of data on effective interventions. We describe the implementation of a multifaceted equity improvement strategy in a pediatric ED using Kotter's model for change as a framework to identify the key drivers. The main elements included a data dashboard with quality metrics stratified by patient self-reported REaL to visualize disparities, a staff workshop on implicit bias and microaggressions, and several clinical and operational tools that highlight equity. Our next steps include refining and repeating interventions and tracking important patient outcomes, including timely pain treatment, triage assessment, diagnostic evaluations, and interpreter use, with the overall goal of improving patient equity by REaL over time. This article presents a roadmap for a disparity reduction intervention, which can be part of a multifaceted approach to address health equity in EDs.
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Affiliation(s)
- Emily A Hartford
- University of Washington, Department Pediatrics, Division of Emergency Medicine, Seattle, WA, USA.
| | - Anita A Thomas
- University of Washington, Department Pediatrics, Division of Emergency Medicine, Seattle, WA, USA
| | - Olivia Kerwin
- Seattle Children's Hospital Emergency Department, Seattle, WA, USA
| | - Etiowo Usoro
- Seattle Children's Hospital Emergency Department, Seattle, WA, USA
| | - Hiromi Yoshida
- University of Washington, Department Pediatrics, Division of Emergency Medicine, Seattle, WA, USA
| | - Brian Burns
- Seattle Children's Hospital Emergency Department, Seattle, WA, USA
| | - Lori E Rutman
- University of Washington, Department Pediatrics, Division of Emergency Medicine, Seattle, WA, USA
| | - Russell Migita
- University of Washington, Department Pediatrics, Division of Emergency Medicine, Seattle, WA, USA
| | | | - Sabreen Akhter
- University of Washington, Department Pediatrics, Division of Emergency Medicine, Seattle, WA, USA
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22
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Goldfarb SS, Graves K, Geletko K, Hansen MD, Kinsell H, Harman J. Racial and Ethnic Differences in Emergency Department Wait Times for Patients with Substance Use Disorder. J Emerg Med 2023; 64:481-487. [PMID: 36997432 DOI: 10.1016/j.jemermed.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/03/2023] [Accepted: 02/17/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Substance use-related morbidity and mortality rates are at an all-time high in the United States, yet there remains significant stigma and discrimination in emergency medicine about patients with this condition. OBJECTIVES The purpose of this study was to determine whether there are racial and ethnic differences in emergency department (ED) wait times among patients with substance use disorder. METHODS The study uses pooled data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2016 to 2018. The dependent variable is length of time the patient with a diagnosis of substance use disorder waited in the ED before being admitted for care. The independent variable is patient race and ethnicity. Adjusted analyses were conducted using a generalized linear model. RESULTS There were a total of 3995 reported ED events among patients reporting a substance use disorder in the NHAMCS sample between 2016 and 2018. After adjusting for covariates, Black patients with substance use disorder were significantly more likely to wait longer in the ED (35% longer) than White patients with substance use disorder (p < 0.01). CONCLUSIONS The findings showed that Black patients with substance use disorder are waiting 35% longer, on average, than White patients with the same condition. This is concerning, given that emergency medicine is a critical frontline of care, and often the only source of care, for these patients. Furthermore, longer wait times can increase the likelihood of leaving the ED without being seen. Programs and policies should address potential stigma and discrimination among providers, and EDs should consider adding people with lived experiences to the staff to serve as peer recovery specialists and bridge the gap for care.
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Affiliation(s)
- Samantha Sittig Goldfarb
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee
| | - Katelyn Graves
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee
| | - Karen Geletko
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee
| | - Megan Deichen Hansen
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee
| | - Heidi Kinsell
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee
| | - Jeff Harman
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee
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Pickel J, Fiks AG, Karavite D, Maleki P, Beidas RS, Dowshen N, Petsis D, Gross R, Wood SM. Provider perspectives on clinical decision support to improve HIV prevention in pediatric primary care: a multiple methods study. Implement Sci Commun 2023; 4:18. [PMID: 36810099 DOI: 10.1186/s43058-023-00394-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 01/25/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Clinical decision support (CDS) is a promising intervention for improving uptake of HIV testing and pre-exposure prophylaxis (PrEP). However, little is known regarding provider perspectives on acceptability, appropriateness, and feasibility of CDS for HIV prevention in pediatric primary care, a key implementation setting. METHODS This was a cross-sectional multiple methods study utilizing surveys and in-depth interviews with pediatricians to assess acceptability, appropriateness, and feasibility of CDS for HIV prevention, as well as to identify contextual barriers and facilitators to CDS. Qualitative analysis utilized work domain analysis and a deductive coding approach grounded in the Consolidated Framework of Implementation Research. Quantitative and qualitative data were merged to develop an Implementation Research Logic Model to conceptualize implementation determinants, strategies, mechanisms, and outcomes of potential CDS use. RESULTS Participants (n = 26) were primarily white (92%), female (88%), and physicians (73%). Using CDS to improve HIV testing and PrEP delivery was perceived as highly acceptable (median score 5), IQR [4-5]), appropriate (5, IQR [4-5]), and feasible (4, IQR [3.75-4.75]) using a 5-point Likert scale. Providers identified confidentiality and time constraints as two key barriers to HIV prevention care spanning every workflow step. With respect to desired CDS features, providers sought interventions that were integrated into the primary care workflow, standardized to promote universal testing yet adaptable to the level of a patient's HIV risk, and addressed providers' knowledge gaps and bolstered self-efficacy in providing HIV prevention services. CONCLUSIONS This multiple methods study indicates that clinical decision support in the pediatric primary care setting may be an acceptable, feasible, and appropriate intervention for improving the reach and equitable delivery of HIV screening and PrEP services. Design considerations for CDS in this setting should include deploying CDS interventions early in the visit workflow and prioritizing standardized but flexible designs.
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Chernick LS, Bugaighis M, Britton L, Cruz AT, Goyal MK, Mistry RD, Reed JL, Bakken S, Santelli JS, Dayan PS. Factors influencing the conduction of confidential conversations with adolescents in the emergency department: A multicenter, qualitative analysis. Acad Emerg Med 2023; 30:99-109. [PMID: 36478023 DOI: 10.1111/acem.14638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Health care providers (HCPs) in the emergency department (ED) frequently must decide whether to conduct or forego confidential conversations with adolescent patients about sensitive topics, such as those related to mental health, substance use, and sexual and reproductive health. The objective of this multicenter qualitative analysis was to identify factors that influence the conduct of confidential conversations with adolescent patients in the ED. METHODS In this qualitative study, we conducted semistructured interviews of ED HCPs from five academic, pediatric EDs in distinct geographic regions. We purposively sampled HCPs across gender, professional title, and professional experience. We used the Theoretical Domains Framework (TDF) to develop an interview guide to assess individual and system-level factors affecting HCP behavior regarding the conduct of confidential conversations with adolescents. Enrollment continued until we reached saturation. Interviews were recorded, transcribed, and coded by three investigators based on thematic analysis. We used the coded transcripts to collaboratively generate belief statements, which are first-person statements that reflect shared perspectives. RESULTS We conducted 38 interviews (18 physicians, 11 registered nurses, five nurse practitioners, and four physician assistants). We generated 17 belief statements across nine TDF domains. Predominant influences on having confidential conversations included self-efficacy in speaking with adolescents alone, wanting to address sexual health complaints, maintaining patient flow, experiencing parental resistance and limited space, and having inadequate resources to address patient concerns and personal preconceptions about patients. Perspectives divided between wanting to provide focused medical care related only to their chief complaint versus self-identifying as a holistic medical HCP. CONCLUSIONS The factors influencing the conduct of confidential conversations included multiple TDF domains, elucidating how numerous intersecting factors influence whether ED HCPs address sensitive adolescent health needs. These data suggest methods to enhance and facilitate confidential conversations when deemed appropriate in the care of adolescents in the ED.
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Affiliation(s)
- Lauren S Chernick
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA.,Department of Population and Family Health, Columbia University, New York, New York, USA
| | - Mona Bugaighis
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Laura Britton
- Department of Nursing, Columbia University Irving Medical Center, New York, New York, USA
| | - Andrea T Cruz
- Divisions of Emergency Medicine and Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Monika K Goyal
- Department of Pediatrics, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Rakesh D Mistry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jennifer L Reed
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Ohio, Cincinnati, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Ohio, Cincinnati, USA
| | - Suzanne Bakken
- Department of Nursing and Bioinformatics, Columbia University Irving Medical Center, New York, New York, USA
| | - John S Santelli
- Department of Population and Family Health, Columbia University, New York, New York, USA.,Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Peter S Dayan
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
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Gavaza P, Rawal BM, Flynn P. An exploratory qualitative study of pharmacy student perspectives of implicit bias in pharmacy practice. Curr Pharm Teach Learn 2023; 15:43-51. [PMID: 36907693 DOI: 10.1016/j.cptl.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/28/2022] [Accepted: 02/23/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Implicit biases can contribute to unfair treatment in healthcare and exacerbate healthcare disparities. Little is known about the implicit biases that exist within pharmacy practice and their behavioral manifestations. The purpose of this study was to explore pharmacy student perspectives about implicit bias in pharmacy practice. METHODS Sixty-two second-year pharmacy students attended a lecture on implicit bias in healthcare and engaged in an assignment designed to explore their thoughts about how implicit bias manifests or may manifest within pharmacy practice. Students' qualitative responses were content analyzed. RESULTS Students reported several examples in which implicit bias may emerge in pharmacy practice. Various forms of potential bias were identified including bias associated with patients' race, ethnicity, and culture, insurance/financial status, weight, age, religion, physical appearance and language, lesbian, gay, bisexual, transgender, queer/questioning and gender identity, and prescriptions filled. Students identified several potential implications of implicit bias in pharmacy practice including unwelcoming non-verbal behavior on the part of providers, differences in time devoted to interacting with patients, differences in empathy and respect, inadequate counseling, and (un)willingness to provide services. Students also identified factors that could precipitate biased behaviors such as fatigue, stress, burnout, and multiple demands. CONCLUSIONS Pharmacy students believed that implicit biases manifested in many different ways and were potentially associated with behaviors that resulted in unequal treatment in pharmacy practice. Future studies should explore the effectiveness of implicit bias trainings on reducing the behavioral implications of bias in pharmacy practice.
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Affiliation(s)
- Paul Gavaza
- Loma Linda University School of Pharmacy, 24745 Stewart Street, Loma Linda, CA 92350, United States.
| | - Bhaktidevi M Rawal
- Loma Linda University School of Pharmacy, 24745 Stewart Street, Loma Linda, CA 92350, United States.
| | - Patricia Flynn
- Department of Psychology, Loma Linda University School of Behavioral Health, Department of Preventive Medicine, School of Medicine, Loma Linda, CA 92350, United States.
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Jin RO, Anaebere TC, Haar RJ. Exploring Bias in Restraint Use: Four Strategies to Mitigate Bias in Care of the Agitated Patient in the Emergency Department. Focus (Am Psychiatr Publ) 2023; 21:100-105. [PMID: 37205039 PMCID: PMC10172532 DOI: 10.1176/appi.focus.23022007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethicolegal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional, and health system level to help mitigate bias and improve care. Reprinted from Acad Emerg Med 2021; 28:1061-1066, with permission from John Wiley & Sons. Copyright © 2021.
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Affiliation(s)
- Rowen O. Jin
- Department of Emergency Medicine, LAC+USC Medical Center, Los Angeles, California, USA (Jin). Special Projects and Innovation, Emergency Medicine Residency Program, Dignity Health–St. Joseph’s Medical Center, Stockton, California, USA (Anaebere). Department of Epidemiology and Biostatistics, University of California at Berkeley, Berkeley, California, USA (Haar)
| | - Tiffany C. Anaebere
- Department of Emergency Medicine, LAC+USC Medical Center, Los Angeles, California, USA (Jin). Special Projects and Innovation, Emergency Medicine Residency Program, Dignity Health–St. Joseph’s Medical Center, Stockton, California, USA (Anaebere). Department of Epidemiology and Biostatistics, University of California at Berkeley, Berkeley, California, USA (Haar)
| | - Rohini J. Haar
- Department of Emergency Medicine, LAC+USC Medical Center, Los Angeles, California, USA (Jin). Special Projects and Innovation, Emergency Medicine Residency Program, Dignity Health–St. Joseph’s Medical Center, Stockton, California, USA (Anaebere). Department of Epidemiology and Biostatistics, University of California at Berkeley, Berkeley, California, USA (Haar)
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Tjia J, Pugnaire M, Calista J, Eisdorfer E, Hale J, Terrien J, Valdman O, Potts S, Garcia M, Yazdani M, Puerto G, Okero M, Duodu V, Sabin J. Using Simulation-Based Learning with Standardized Patients (SP) in an Implicit Bias Mitigation Clinician Training Program. J Med Educ Curric Dev 2023; 10:23821205231175033. [PMID: 37324051 PMCID: PMC10265320 DOI: 10.1177/23821205231175033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 04/24/2023] [Indexed: 06/17/2023]
Abstract
Objectives To describe the development and refinement of an implicit bias recognition and management training program for clinical trainees. Methods In the context of an NIH-funded clinical trial to address healthcare disparities in hypertension management, research and education faculty at an academic medical center used a participatory action research approach to engage local community members to develop and refine a "knowledge, awareness, and skill-building" bias recognition and mitigation program. The program targeted medical residents and Doctor of Nursing Practice students. The content of the two-session training included: didactics about healthcare disparities, racism and implicit bias; implicit association test (IAT) administration to raise awareness of personal implicit bias; skill building for bias-mitigating communication; and case scenarios for skill practice in simulation-based encounters with standardized patients (SPs) from the local community. Results The initial trial year enrolled n = 65 interprofessional participants. Community partners and SPs who engaged throughout the design and implementation process reported overall positive experiences, but SPs expressed need for greater faculty support during in-person debriefings following simulation encounters to balance power dynamics. Initial year trainee participants reported discomfort with intensive sequencing of in-person didactics, IATs, and SP simulations in each of the two training sessions. In response, authors refined the training program to separate didactic sessions from IAT administration and SP simulations, and to increase safe space, and trainee and SP empowerment. The final program includes more interactive discussions focused on identity, race and ethnicity, and strategies to address local health system challenges related to structural racism. Conclusion It is possible to develop and implement a bias awareness and mitigation skills training program that uses simulation-based learning with SPs, and to engage with local community members to tailor the content to address the experience of local patient populations. Further research is needed to measure the success and impact of replicating this approach elsewhere.
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Affiliation(s)
- Jennifer Tjia
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
| | - Michele Pugnaire
- Department of Family Medicine and Community Health, UMass Chan Medical School, Worcester, MA, USA
| | - Joanne Calista
- Department of Family Medicine and Community Health, UMass Chan Medical School, Worcester, MA, USA
- Executive Director, Center for Health Impact, Worcester, MA, USA
| | - Ethan Eisdorfer
- Department of Family Medicine and Community Health, UMass Chan Medical School, Worcester, MA, USA
| | - Janet Hale
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, MA, USA
| | - Jill Terrien
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, MA, USA
| | - Olga Valdman
- Department of Family Medicine and Community Health, UMass Chan Medical School, Worcester, MA, USA
| | - Stacy Potts
- Department of Family Medicine and Community Health, UMass Chan Medical School, Worcester, MA, USA
| | - Maria Garcia
- Department of Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Majid Yazdani
- Department of Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Geraldine Puerto
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
| | - Miriam Okero
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, MA, USA
| | - Vennesa Duodu
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
| | - Janice Sabin
- Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle, WA, USA
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Robinson L, Cramer LD, Ray JM, Brashear TK, Agboola IK, Bernstein SL, Taylor RA, Wong AH. Racial and ethnic disparities in use of chemical restraint in the emergency department. Acad Emerg Med 2022; 29:1496-1499. [PMID: 35934988 PMCID: PMC9771988 DOI: 10.1111/acem.14579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/18/2022] [Accepted: 08/05/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Leah Robinson
- Yale School of Public Health, Yale School of Medicine, New Haven, CT, USA
| | - Laura D. Cramer
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, USA
| | - Jessica M. Ray
- Department of Health Outcomes & Biomedical Informatics, University of Florida College of Medicine, Gainesville, FL, USA
| | - Taylor K. Brashear
- Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Isaac K. Agboola
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Steven L. Bernstein
- Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | - Ambrose H. Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
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29
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Darby A, Cleveland Manchanda EC, Janeway H, Samra S, Hicks MN, Long R, Gipson KA, Chary AN, Adjei BA, Khanna K, Pierce A, Kaltiso SAO, Spadafore S, Tsai J, Dekker A, Thiessen ME, Foster J, Diaz R, Mizuno M, Schoenfeld E. Race, racism, and antiracism in emergency medicine: A scoping review of the literature and research agenda for the future. Acad Emerg Med 2022; 29:1383-1398. [PMID: 36200540 DOI: 10.1111/acem.14601] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/23/2022] [Accepted: 09/25/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The objective was to conduct a scoping review of the literature and develop consensus-derived research priorities for future research inquiry in an effort to (1) identify and summarize existing research related to race, racism, and antiracism in emergency medicine (EM) and adjacent fields and (2) set the agenda for EM research in these topic areas. METHODS A scoping review of the literature using PubMed and EMBASE databases, as well as review of citations from included articles, formed the basis for discussions with community stakeholders, who in turn helped to inform and shape the discussion and recommendations of participants in the Society for Academic Emergency Medicine (SAEM) consensus conference. Through electronic surveys and two virtual meetings held in April 2021, consensus was reached on terminology, language, and priority research questions, which were rated on importance or impact (highest, medium, lower) and feasibility or ease of answering (easiest, moderate, difficult). RESULTS A total of 344 articles were identified through the literature search, of which 187 met inclusion criteria; an additional 34 were identified through citation review. Findings of racial inequities in EM and related fields were grouped in 28 topic areas, from which emerged 44 key research questions. A dearth of evidence for interventions to address manifestations of racism in EM was noted throughout. CONCLUSIONS Evidence of racism in EM emerged in nearly every facet of our literature. Key research priorities identified through consensus processes provide a roadmap for addressing and eliminating racism and other systems of oppression in EM.
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Affiliation(s)
- Anna Darby
- Department of Emergency Medicine, Los Angeles County and University of Southern California Medical Center, Los Angeles, California, USA
| | | | - Hannah Janeway
- Department of EM, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Shamsher Samra
- Department of EM, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Marquita Norman Hicks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ruby Long
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Katrina A Gipson
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anita N Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Brenda A Adjei
- National Cancer Institute Division of Cancer Control and Population Sciences, Bethesda, Maryland, USA
| | - Kajal Khanna
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ava Pierce
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sheri-Ann O Kaltiso
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sophia Spadafore
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jennifer Tsai
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Annette Dekker
- Department of EM, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Molly E Thiessen
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Jordan Foster
- Department of Emergency Medicine, Columbia University Medical Center, New York, New York, USA
| | - Rose Diaz
- Department of EM, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California, USA
| | - Mikaela Mizuno
- University of California, Riverside School of Medicine, Riverside, California, USA
| | - Elizabeth Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
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30
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Deichen Hansen ME, Goldfarb SS, Mercouffer A, Dark T, Lateef H, Harman JS. Racial inequities in emergency department wait times for pregnancy-related concerns. Womens Health (Lond) 2022; 18:17455057221129388. [PMID: 36300291 PMCID: PMC9623347 DOI: 10.1177/17455057221129388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: Emergency department care is common among US pregnant women. Given the
increased likelihood of serious and life-threatening pregnancy-related
health conditions among Black mothers, timeliness of emergency department
care is vital. The objective of this study was to evaluate racial/ethnic
variations in emergency department wait times for receiving obstetrical care
among a nationally representative population. Methods: The study used pooled 2016–2018 data from the National Hospital Ambulatory
Medical Care Survey, a nationally representative sample of emergency
department visits. Regression models were estimated to determine whether
emergency department wait time was associated with the race/ethnicity of the
perinatal patient. Adjusted models controlled for age, obesity status,
insurance type, whether the patient arrived by ambulance, triage status,
presence of a patient dashboard, and region. Results: There were a total of 821 reported pregnancy-related visits in the National
Hospital Ambulatory Medical Care Survey sample of emergency department
visits. Of those 821 visits, 40.6% were among White women, 27.7% among Black
women, and 27.5% among Hispanic women. Mean wait times differed
substantially by race/ethnicity. After adjusting for potential confounders,
Black women waited 46% longer than White women with emergency department
visits for pregnancy problems (p < .05). Those reporting another race
waited 95% longer for pregnancy problems in the emergency department than
White women (p < .05). Conclusion: Findings from this study document significant racial/ethnic differences in
wait times for perinatal emergency department care. Although inequities in
wait times may emerge across the spectrum of care, documenting the factors
influencing racial disparities in wait times are critical to promoting
equitable perinatal health outcomes.
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Affiliation(s)
- Megan E Deichen Hansen
- Megan E Deichen Hansen, Department of
Behavioral Sciences and Social Medicine, College of Medicine, Florida State
University, 1115 W Call St, Tallahassee, FL 32304, USA.
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Rajbhandari P, Garber MD. Improving Language Equity in Hospitalized Children of Families With LEP: Challenges and Solutions. Hosp Pediatr 2022; 12:e367-e373. [PMID: 36124635 DOI: 10.1542/hpeds.2022-006537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Prabi Rajbhandari
- Division of Hospital Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, Ohio
| | - Matthew D Garber
- Division of Hospital Medicine, Department of Pediatrics, Wolfson Children's Hospital University of Florida Health, Jacksonville, Florida
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Davuluri K, Goyal N, Gomez Acevedo H, Folt J, Jayaprakash N, Slezak M, Caldwell MT. Patient perspectives of the climate of diversity, equity, and inclusion in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12798. [PMID: 36176501 PMCID: PMC9482342 DOI: 10.1002/emp2.12798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 06/02/2022] [Accepted: 06/14/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Assessing the diversity, equity, and inclusion (DEI) climate of emergency departments (EDs) can inform organizational change to provide equitable, inclusive, and high‐quality care to their diverse patient populations. The purpose of this project was to investigate patient perspectives on the climate of DEI in an urban ED. Methods This was a cross‐sectional survey study conducted in a large‐volume, urban ED in Detroit, MI, from November 2018 to January 2019. The survey was developed by an experienced ED DEI committee via an iterative process and broad consensus. Results During their care in the ED, 849 patients completed an anonymous survey about their perspectives and experiences of DEI in that ED. Overall, the responses were favorable as most respondents reported that the ED staff treated patients from all races equally (75.8%) and made patients feel accepted (86%). However, some respondents felt that the ED staff's treatment of populations with greater complexity, such as patients who are mentally ill (16.8%) or lower income (14.3%), needs the most improvement. Conclusions This DEI climate assessment survey of ED patients’ perspectives revealed important insights that could guide strategic initiatives to advance DEI in the ED. This assessment may serve as a model for continuous evaluation of DEI over time and in multiple healthcare settings to help guide organizational change efforts.
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Affiliation(s)
- Kavya Davuluri
- University of Michigan Medical School Ann Arbor Michigan USA
| | - Nikhil Goyal
- Department of Emergency Medicine Henry Ford Health System Detroit Michigan USA
- Department of Internal Medicine Henry Ford Health System Detroit Michigan USA
| | - Harold Gomez Acevedo
- Department of Emergency Medicine Kendall Regional Medical Center Miami Florida USA
| | - Jason Folt
- Department of Emergency Medicine Henry Ford Health System Detroit Michigan USA
| | - Namita Jayaprakash
- Department of Emergency Medicine Henry Ford Health System Detroit Michigan USA
- Division of Pulmonary and Critical Care Medicine Henry Ford Health System Detroit Michigan USA
| | - Michelle Slezak
- Department of Emergency Medicine Henry Ford Health System Detroit Michigan USA
| | - Martina T. Caldwell
- Department of Emergency Medicine Henry Ford Health System Detroit Michigan USA
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Lewis TR, Kielt MJ, Walker VP, Levin JC, Guaman MC, Panitch HB, Nelin LD, Abman SH. Association of Racial Disparities With In-Hospital Outcomes in Severe Bronchopulmonary Dysplasia. JAMA Pediatr 2022; 176:852-859. [PMID: 35913704 PMCID: PMC9344383 DOI: 10.1001/jamapediatrics.2022.2663] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) is the most common serious morbidity of preterm birth. Short-term respiratory outcomes for infants with the most severe forms of BPD are highly variable. The mechanisms that explain this variability remain unknown and may be mediated by racial disparities. OBJECTIVE To determine the association of maternal race with death and length of hospital stay in a multicenter cohort of infants with severe BPD. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study included preterm infants enrolled in the BPD Collaborative registry from January 1, 2015, to July 19, 2021, involving 8 BPD Collaborative centers located in the US. Included patients were born at less than 32 weeks' gestation, had a diagnosis of severe BPD as defined by the 2001 National Institutes of Health Consensus Criteria, and were born to Black or White mothers. EXPOSURES Maternal race: Black vs White. MAIN OUTCOMES AND MEASURES Death and length of hospital stay. RESULTS Among 834 registry infants (median [IQR] gestational age, 25 [24-27] weeks; 492 male infants [59%]) meeting inclusion criteria, the majority were born to White mothers (558 [67%]). Death was observed infrequently in the study cohort (32 [4%]), but Black maternal race was associated with an increased odds of death (adjusted odds ratio, 2.1; 95% CI, 1.2-3.5) after adjusting for center. Black maternal race was also significantly associated with length of hospital stay (adjusted between-group difference, 10 days; 95% CI, 3-17 days). CONCLUSIONS AND RELEVANCE In a multicenter severe BPD cohort, study results suggest that infants born to Black mothers had increased likelihood of death and increased length of hospital stay compared with infants born to White mothers. Prospective studies are needed to define the sociodemographic mechanisms underlying disparate health outcomes for Black infants with severe BPD.
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Affiliation(s)
- Tamorah R. Lewis
- Children’s Mercy Hospital, The University of Missouri—Kansas City, Kansas City
| | - Matthew J. Kielt
- Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | - Valencia P. Walker
- Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | - Jonathan C. Levin
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Howard B. Panitch
- Children’s Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia
| | - Leif D. Nelin
- Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | - Steven H. Abman
- Children's Hospital Colorado, The University of Colorado School of Medicine, Aurora
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Fraiman YS, Cheston CC, Morales D, Leeman KT, Hansen AR. A mixed methods study of perceptions of bias among neonatal intensive care unit staff. Pediatr Res 2022. [PMID: 36038641 DOI: 10.1038/s41390-022-02217-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 06/07/2022] [Accepted: 07/12/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Inequity in neonatology may be potentiated within neonatal intensive care units (NICUs) by the effects of bias. Addressing bias can lead to improved, more equitable care. Understanding perceptions of bias can inform targeted interventions to reduce the impact of bias. We conducted a mixed methods study to characterize the perceptions of bias among NICU staff. METHODS Surveys were distributed to all staff (N = 245) in a single academic Level IV NICU. Respondents rated the impact of bias on their own and others' behaviors on 5-point Likert scales and answered one open-ended question. Kruskal-Wallis test (KWT) and Levene's test were used for quantitative analysis and thematic analysis was used for qualitative analysis. RESULTS We received 178 responses. More respondents agreed that bias had a greater impact on others' vs. their own behaviors (KWT p < 0.05). Respondents agreed that behaviors were influenced more by implicit than explicit biases (KWT p < 0.05). Qualitative analysis resulted in nine unique themes. CONCLUSIONS Staff perceive a high impact of bias across different domains with increased perceived impact of implicit vs. explicit bias. Staff perceive a greater impact of others' biases vs. their own. Mixed methods studies can help identify unique, unit-responsive approaches to reduce bias. IMPACT Healthcare staff have awareness of bias and its impact on their behaviors with patients, families, and staff. Healthcare staff believe that implicit bias impacts their behaviors more than explicit bias, and that they have less bias than others. Healthcare staff have ideas for strategies and approaches to mitigate the impact of bias. Mixed method studies are effective ways of understanding environment-specific perceptions of bias, and contextual assets and barriers when creating interventions to reduce bias and improve equity. Generating interventions to reduce the impact of bias in healthcare requires a context-specific understanding of perceptions of bias among staff.
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Desai P, Haut L, Wagers B, Coffee RL, Kelker H, Wyderko M, Sarmiento EJ, Kanis J. Identification of Bias in Ordering Further Imaging in Ethnic Groups With Indeterminate Ultrasound for Appendicitis. Cureus 2022; 14:e28109. [PMID: 36158353 PMCID: PMC9491685 DOI: 10.7759/cureus.28109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 08/17/2022] [Indexed: 11/05/2022] Open
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Gainsburg I, Derricks V, Shields C, Fiscella K, Epstein R, Yu V, Griggs J. Patient activation reduces effects of implicit bias on doctor-patient interactions. Proc Natl Acad Sci U S A 2022; 119:e2203915119. [PMID: 35914161 DOI: 10.1073/pnas.2203915119] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Disparities between Black and White Americans persist in medical treatment and health outcomes. One reason is that physicians sometimes hold implicit racial biases that favor White (over Black) patients. Thus, disrupting the effects of physicians' implicit bias is one route to promoting equitable health outcomes. In the present research, we tested a potential mechanism to short-circuit the effects of doctors' implicit bias: patient activation, i.e., having patients ask questions and advocate for themselves. Specifically, we trained Black and White standardized patients (SPs) to be "activated" or "typical" during appointments with unsuspecting oncologists and primary care physicians in which SPs claimed to have stage IV lung cancer. Supporting the idea that patient activation can promote equitable doctor-patient interactions, results showed that physicians' implicit racial bias (as measured by an implicit association test) predicted racially biased interpersonal treatment among typical SPs (but not among activated SPs) across SP ratings of interaction quality and ratings from independent coders who read the interaction transcripts. This research supports prior work showing that implicit attitudes can undermine interpersonal treatment in medical settings and provides a strategy for ensuring equitable doctor-patient interactions.
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Dickerson-Young T, Uspal NG, Prince WB, Qu P, Klein EJ. Racial and Ethnic Differences in Ondansetron Use for Acute Gastroenteritis in Children. Pediatr Emerg Care 2022; 38:380-385. [PMID: 35353794 DOI: 10.1097/pec.0000000000002610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES There is limited research examining racial/ethnic disparities in antiemetic use for acute gastroenteritis (AGE). We assessed racial/ethnic differences in the care of children with AGE. METHODS The Pediatric Health Information System was used to conduct a retrospective cohort study of children 6 months to 6 years old with AGE seen in participating emergency departments from 2016 to 2018. Cases were identified using International Classification of Diseases, Tenth Revision codes. The primary outcome was administration of ondansetron, secondary outcomes were administration of intravenous (IV) fluids and hospitalization, and primary predictor was race/ethnicity. Multivariable logistic regression followed by a mixed model adjusted for sex, age, insurance, and hospital to examine the association of race/ethnicity with each outcome. RESULTS There were 78,019 encounters included; 24.8% of patients were non-Hispanic White (NHW), 29.0% non-Hispanic Black (NHB), 37.3% Hispanic, and 8.9% other non-Hispanic (NH) race/ethnicity. Compared with NHW patients, minority children were more likely to receive ondansetron (NHB: adjusted odds ratio, 1.36 [95% confidence interval, 1.2-1.55]; Hispanic: 1.26 [1.1-1.44]; other NH: 1.22 [1.07-1.4]). However, minority children were less likely to receive IV fluids (NHB: 0.38 [0.33-0.43]; Hispanic: 0.44 [0.36-0.53]; other NH: 0.51 [0.44-0.61]) or hospital admission (NHB: 0.37 [0.29-0.48]; Hispanic: 0.41 [0.33-0.5]; other NH: 0.52 [0.41-0.66]). Ondansetron use by hospital ranged from 73% to 95%. CONCLUSIONS This large database analysis of emergency departments around the nation found that NHW patients were less likely to receive ondansetron but more likely to receive IV fluids and hospital admission than minority patients. These findings are likely multifactorial and may represent bias, social determinants of health, access to care, or illness severity among other possible causes.
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Affiliation(s)
| | | | | | - Pingping Qu
- Biostatistics Epidemiology and Analytics in Research (BEAR), Seattle Children's Research Institute, Seattle, WA
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Abstract
INTRODUCTION Racial and ethnic minority patients continue to experience disparities in health care. It is important to understand provider-level factors that may contribute to these inequities. This study aims to evaluate the presence of implicit racial bias among pediatric orthopaedic surgeons and determine the relationship between bias and clinical decision making. METHODS A web-based survey was distributed to 415 pediatric orthopaedic surgeons. One section measured for potential implicit racial bias using a child-race implicit association test (IAT). IAT scores were compared with US physicians and the US general population using publicly available data. Another section consisted of clinical vignettes with associated questions. For each vignette, surgeons were randomly assigned a single race-version, White or Black. Vignette questions were grouped into an opioid recommendation, management decision, or patient perception category for analysis based on subject tested. Vignette answers from surgeons with IAT scores that were concordant with their randomized vignette race-version (ie, surgeon with pro-White score assigned White vignette version) were compared with those that were discordant. RESULTS IAT results were obtained from 119 surveyed surgeons (29% response rate). Overall, respondents showed a minor pro-White implicit bias ( P <0.001). Implicit bias of any strength toward either race was present among 103/119 (87%) surgeons. The proportion of pediatric orthopaedic surgeons with a strong pro-White implicit bias (29%) was greater than that of US physicians overall (21%, P =0.032) and the US general population (19%, P =0.004). No differences were found in overall opioid recommendations, management decisions, or patient perceptions between concordant and discordant groups. CONCLUSION Most of the pediatric orthopaedic surgeons surveyed demonstrated implicit racial bias on IAT testing, with a large proportion demonstrating strong pro-White bias. Despite an association between implicit bias and clinical decision making in the literature, this study observed no evidence that implicit racial bias affected the management of pediatric fractures. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Ryan Guzek
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia
| | | | - Lori Jia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Coleen S Sabatini
- Department of Orthopaedic Surgery, University of California San Francisco and UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Wudbhav N Sankar
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Brendan A Williams
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Apurva S Shah
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Elkbuli A, Fanfan D, Newsome K, Sutherland M, Liu H, McKenney M, Ang D. A national evaluation of emergency department thoracotomy practices: Will a high-risk, low-yield procedure reveal potential management practice bias? Surgery 2022; 172:410-420. [PMID: 34972592 DOI: 10.1016/j.surg.2021.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 11/17/2021] [Accepted: 11/29/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Emergency department thoracotomy is often performed on patients in extremis from traumatic exsanguination. Thus, inherent biases may play a role in whether or not the emergency department thoracotomy is performed. We aimed to investigate race, socioeconomic status, and gender disparities in the use of emergency department thoracotomy and to investigate outcomes of these patients to assess for possible surgeon practice bias. METHOD A nationwide retrospective cohort analysis of the American College of Surgeons Trauma Quality Programs Participant Use Profile 2016-2018. Adult patients who suffered blunt, penetrating, or other injuries secondary to falls/firearms/motor vehicle collision/other mechanisms of injury and presented to a trauma center pulseless, with or without signs of life after injury. Rates of thoracotomy, time to thoracotomy, transfer to operating room, emergency department disposition, intensive care unit length of stay, hospital length of stay, complications, mortality, and hospital disposition. Univariate analyses and adjusted multivariable regression were performed to account for confounders with significance defined as P < .05. RESULTS A total of 6,453 patients were analyzed. Emergency department thoracotomy and mortality were significantly higher in minorities and uninsured patients, even after risk adjustment. There were no differences in timing among race groups to emergency department thoracotomy. White/Caucasian patients experienced the highest rate of emergency department initial disposition to the intensive care unit (10.3%, P < .0001) and lowest mortality rate (89.2%, P < .0001). CONCLUSION Surgeon bias was not seen in the practice of emergency department thoracotomy for patients arriving pulseless. However, poorer outcomes were associated with minorities and lower socioeconomic status patients. Thoracotomy rates were higher in minorities and lower socioeconomic status patients due to more penetrating trauma.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL.
| | - Dino Fanfan
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Kevin Newsome
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL
| | - Huazhi Liu
- Department of Surgery, Ocala Regional Medical Center, FL
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL; Department of Surgery, University of South Florida, Tampa, FL
| | - Darwin Ang
- Department of Surgery, Ocala Regional Medical Center, FL; Department of Surgery, University of Central Florida, Ocala, FL
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Alter SM, Temple CA, Solano JJ, Hughes PG, Clayton LM, Shih RD. Time from hospital presentation to head imaging in white, black, and Hispanic geriatric trauma patients. Am J Emerg Med 2022; 59:152-155. [DOI: 10.1016/j.ajem.2022.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 05/17/2022] [Accepted: 06/28/2022] [Indexed: 11/17/2022] Open
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Longcoy J, Patwari R, Hasler S, Johnson T, Avery E, Stefanini K, Suzuki S, Ansell D, Lynch E. Racial and Ethnic Differences in Hospital Admissions of Emergency Department COVID-19 Patients. Med Care 2022; 60:415-422. [PMID: 35315379 PMCID: PMC9093229 DOI: 10.1097/mlr.0000000000001710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND Several studies have found that among patients testing positive for COVID-19 within a health care system, non-Hispanic Black and Hispanic patients are more likely than non-Hispanic White patients to be hospitalized. However, previous studies have looked at odds of being admitted using all positive tests in the system and not only those seeking care in the emergency department (ED). OBJECTIVE This study examined racial/ethnic differences in COVID-19 hospitalizations and intensive care unit (ICU) admissions among patients seeking care for COVID-19 in the ED. RESEARCH DESIGN Electronic health records (n=7549) were collected from COVID-19 confirmed patients that visited an ED of an urban health care system in the Chicago area between March 2020 and February 2021. RESULTS After adjusting for possible confounders, White patients had 2.2 times the odds of being admitted to the hospital and 1.5 times the odds of being admitted to the ICU than Black patients. There were no observed differences between White and Hispanic patients. CONCLUSIONS White patients were more likely than Black patients to be hospitalized after presenting to the ED with COVID-19 and more likely to be admitted directly to the ICU. This finding may be due to racial/ethnic differences in severity of disease upon ED presentation, racial and ethnic differences in access to COVID-19 primary care and/or implicit bias impacting clinical decision-making.
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Affiliation(s)
- Joshua Longcoy
- Center for Community Health Equity, Rush University Medical Center
| | | | | | - Tricia Johnson
- Center for Community Health Equity and Department of Health Systems Management, Rush University Medical Center
| | - Elizabeth Avery
- Center for Community Health Equity, Rush University Medical Center and Department of Preventive Medicine, Rush Medical College
| | | | - Sumihiro Suzuki
- Department of Preventive Medicine, Rush Medical College, Chicago, IL
| | - David Ansell
- Center for Community Health Equity, Rush University Medical Center and Department of Preventive Medicine, Rush Medical College
| | - Elizabeth Lynch
- Center for Community Health Equity, Rush University Medical Center and Department of Preventive Medicine, Rush Medical College
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Abstract
BACKGROUND Racism constitutes a barrier towards achieving equitable healthcare as documented in research showing unequal processes of delivering, accessing, and receiving healthcare across countries and healthcare indicators. This review summarizes studies examining how racism is discussed and produced in the process of delivering, accessing and receiving healthcare across various national contexts. METHOD The PRISMA guidelines for scoping reviews were followed and databases were searched for peer reviewed empirical articles in English across national contexts. No starting date limitation was applied for this review. The end date was December 1, 2020. The review scoped 213 articles. The results were summarized, coded and thematically categorized in regards to the aim. RESULTS The review yielded the following categories: healthcare users' experiences of racism in healthcare; healthcare staff's experiences of racism; healthcare staff's racial attitudes and beliefs; effects of racism in healthcare on various treatment choices; healthcare staff's reflections on racism in healthcare and; antiracist training in healthcare. Racialized minorities experience inadequate healthcare and being dismissed in healthcare interactions. Experiences of racism are associated with lack of trust and delay in seeking healthcare. Racialized minority healthcare staff experience racism in their workplace from healthcare users and colleagues and lack of organizational support in managing racism. Research on healthcare staff's racial attitudes and beliefs demonstrate a range of negative stereotypes regarding racialized minority healthcare users who are viewed as difficult. Research on implicit racial bias illustrates that healthcare staff exhibit racial bias in favor of majority group. Healthcare staff's racial bias may influence medical decisions negatively. Studies examining healthcare staff's reflections on racism and antiracist training show that healthcare staff tend to construct healthcare as impartial and that healthcare staff do not readily discuss racism in their workplace. CONCLUSIONS The USA dominates the research. It is imperative that research covers other geo-political contexts. Research on racism in healthcare is mainly descriptive, atheoretical, uses racial categories uncritically and tends to ignore racialization processes making it difficult to conceptualize racism. Sociological research on racism could inform research on racism as it theoretically explains racism's structural embeddedness, which could aid in tackling racism to provide good quality care.
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Affiliation(s)
- Sarah Hamed
- Department of Sociology, Uppsala University, Uppsala, Sweden.
| | - Hannah Bradby
- Department of Sociology, Uppsala University, Uppsala, Sweden
| | - Beth Maina Ahlberg
- Department of Sociology, Uppsala University, Uppsala, Sweden.,Skaraborg Institute for Research and Development, Skövde, Sweden
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Wallis CJD, Jerath A, Kaneshwaran K, Hallet J, Coburn N, Wright FC, Conn LG, Bischof D, Covelli A, Klaassen Z, Zlotta AR, Kulkarni GS, Luckenbaugh AN, Armstrong K, Lim K, Bass B, Detsky AS, Satkunasivam R. Association Between Surgeon and Anesthesiologist Sex Discordance and Postoperative Outcomes: A Population-Based Cohort Study. Ann Surg 2022. [PMID: 35703460 DOI: 10.1097/SLA.0000000000005495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine the effect of surgeon-anesthesiologist sex discordance on postoperative outcomes. SUMMARY BACKGROUND DATA Optimal surgical outcomes depend on teamwork, with surgeons and anesthesiologists forming two key components. There are sex and gender-based differences in interpersonal communication and medical practice which may contribute to patients' perioperative outcomes. METHODS We performed a population-based, retrospective cohort study among adult patients undergoing one of 25 common elective or emergent surgical procedures from 2007-2019 in Ontario, Canada. We assessed the association between differences in sex between surgeon and anesthesiologists (sex discordance) on the primary endpoint of adverse postoperative outcome, defined as death, readmission, or complication within 30-days following surgery using generalized estimating equations. RESULTS Among 1,165,711 patients treated by 3,006 surgeons and 1,477 anesthesiologists, 791,819 patients were treated by sex concordant teams (male surgeon/male anesthesiologist: 747,327 and female surgeon/female anesthesiologist: 44,492) while 373,892 were sex discordant (male surgeon/female anesthesiologist: 267,330 and female surgeon/male anesthesiologist: 106,562). Overall, 12.3% of patients experienced one or more adverse postoperative outcomes of whom 1.3% died. Sex discordance between surgeon and anesthesiologist was not associated with a significant increased likelihood of composite adverse postoperative outcomes (adjusted odds ratio [aOR] 1.00, 95% confidence interval [CI] 0.97-1.03). CONCLUSIONS We did not demonstrate an association between intraoperative surgeon and anesthesiologist sex discordance on adverse postoperative outcomes in a large patient cohort. Patients, clinicians, and administrators may be reassured that physician sex discordance in operating room teams is unlikely to clinically meaningfully affect patient outcomes after surgery.
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Wong AH, Ray JM, Eixenberger C, Crispino LJ, Parker JB, Rosenberg A, Robinson L, McVaney C, Iennaco JD, Bernstein SL, Yonkers KA, Pavlo AJ. Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice. BMJ Open 2022; 12:e059876. [PMID: 35545394 PMCID: PMC9096567 DOI: 10.1136/bmjopen-2021-059876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Agitation, defined as excessive psychomotor activity leading to aggressive or violent behaviour, is prevalent in the emergency department (ED) due to rising behavioural-related visits. Experts recommend use of verbal de-escalation and avoidance of physical restraint to manage agitation. However, bedside applications of these recommendations may be limited by system challenges in emergency care. This qualitative study aims to use a systems-based approach, which considers the larger context and system of healthcare delivery, to identify sociotechnical, structural, and process-related factors leading to agitation events and physical restraint use in the ED. DESIGN Qualitative study using a grounded theory approach to triangulate interviews of patients who have been physically restrained with direct observations of agitation events. SETTING Two EDs in the Northeast USA, one at a tertiary care academic centre and the other at a community-based teaching hospital. PARTICIPANTS We recruited 25 individuals who experienced physical restraint during an ED visit. In addition, we performed 95 observations of clinical encounters of agitation events on unique patients. Patients represented both behavioural (psychiatric, alcohol/drug use) and non-behavioural (medical, trauma) chief complaints. RESULTS Three primary themes with implications for systems-based practice of agitation events in the ED emerged: (1) pathways within health and social systems; (2) interpersonal contexts as reflections of systemic stressors on behavioural emergency care and (3) systems-based and patient-oriented strategies and solutions. CONCLUSIONS Agitation events represented manifestations of patients' structural barriers to care from socioeconomic inequities and high burden of emotional and physical trauma as well as staff members' simultaneous exposure to external stressors from social and healthcare systems. Potential long-term solutions may include care approaches that recognise agitated patients' exposure to psychological trauma, improved coordination within the mental health emergency care network, and optimisation of physical environment conditions and organisational culture.
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Affiliation(s)
- Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jessica M Ray
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Health Outcomes & Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Lauren J Crispino
- Department of Emergency Medicine, Virginia Tech Carilion Clinic, Roanoke, Virginia, USA
| | - John B Parker
- Department of Emergency Medicine, Coliseum Health System, Macon, Georgia, USA
| | | | - Leah Robinson
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Caitlin McVaney
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joanne DeSanto Iennaco
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- Yale School of Nursing, Orange, Connecticut, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Dartmouth-Hitchcock Health System, Lebanon, New Hampshire, USA
| | - Kimberly A Yonkers
- Department of Psychiatry, University of Massachusetts Medical School, Worchester, Massachusetts, USA
| | - Anthony J Pavlo
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
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Loomis AM, Panlilio CC. Trauma-Informed Attitudes, Teacher Stress, and Expulsion Decision Risk in Preschool Classrooms. School Mental Health. [DOI: 10.1007/s12310-022-09513-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Johnson TJ. Antiracism, Black Lives Matter, and Critical Race Theory: The ABCs of Promoting Racial Equity in Pediatric Practice. Pediatr Ann 2022; 51:e95-e106. [PMID: 35293809 DOI: 10.3928/19382359-20220217-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Police shootings of unarmed Black men, women, and children at the intersection of disparities in the setting of the coronavirus disease 2019 pandemic have resulted in a long overdue national awakening regarding race and racism in society. This article defines some of the key terms, providing a foundation to help promote equity in pediatric practice. Although no single article can result in full competency regarding such complex issues, it is meant to provide a foundation for pediatricians on a journey to deepen their knowledge and understanding toward a path to action. [Pediatr Ann. 2022;51(3):e95-e106.].
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Crabtree C, Holbein JB, Monson JQ. Patient traits shape health-care stakeholders' choices on how to best allocate life-saving care. Nat Hum Behav 2022; 6:244-57. [PMID: 35210584 DOI: 10.1038/s41562-021-01280-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 12/14/2021] [Indexed: 11/08/2022]
Abstract
During global pandemics, health-care decision makers often face critical shortages of life-saving medical equipment. How do medical stakeholders prioritize which patients are most deserving of scarce treatment? We report the results of three conjoint experiments conducted in the United States in 2020, testing for biases in US physicians', citizens' and elected politicians' preferences for scarce ventilator distribution. We found that all stakeholders prioritized younger patients and patients who had a higher probability of surviving with ventilator access. When patients' survivability was tied, physicians prioritized patients from racial/ethnic minorities (that is, Asian, Black and Hispanic patients) over all-else-equal white patients, religious minorities (that is, Muslim patients) over religious majority group members (that is, Catholic patients) and patients of lower socio-economic status over wealthier patients. The public also prioritized Black and Hispanic patients over white patients but were biased against religious minorities (that is, Atheist and Muslim patients) relative to religious majority group members. Elected politicians were also biased against Atheist patients. Our effects varied by political party-with Republican physicians, politicians and members of the public showing bias against religious minority patients and Democratic physicians showing preferential treatment of racial and religious minorities. Our results suggest that health-care stakeholders' personal biases impact decisions on who deserves life-saving medical equipment.
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Gutman CK, Holmes S, Balhara KS. Low-value care in pediatric populations: There is no silver lining. Acad Emerg Med 2022; 29:804-807. [PMID: 35212441 DOI: 10.1111/acem.14470] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Colleen K. Gutman
- Department of Emergency Medicine University of Florida College of Medicine Gainesville Florida USA
| | - Sherita Holmes
- Department of Pediatrics Emory University School of Medicine Atlanta Georgia USA
- Division of Emergency Medicine Children's Healthcare of Atlanta Atlanta Georgia USA
| | - Kamna S. Balhara
- Department of Emergency Medicine Johns Hopkins University School of Medicine Baltimore Maryland USA
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Li J, Ramgopal S, Marin JR. Racial and ethnic differences in low-value pediatric emergency care. Acad Emerg Med 2022; 29:698-709. [PMID: 35212440 DOI: 10.1111/acem.14468] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/28/2021] [Accepted: 01/06/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Disparities in health care quality frequently focus on underuse. We evaluated racial/ethnic differences in low-value services delivered in the pediatric emergency department (ED). METHODS We performed a retrospective cross-sectional study of low-value services in children discharged from 39 pediatric EDs from January 2018 to December 2019 using the Pediatric Hospital Information System. Our primary outcome was receipt of one of 12 low-value services across nine conditions, including chest radiography in asthma and bronchiolitis; beta-agonist and corticosteroids in bronchiolitis; laboratory testing and neuroimaging in febrile seizure; neuroimaging in afebrile seizure; head injury and headache; and any imaging in sinusitis, constipation, and facial trauma. We analyzed the association of race/ethnicity on receipt of low-value services using generalized linear mixed models adjusted for age, sex, weekend, hour of presentation, payment, year, household income, and distance from hospital. RESULTS We included 4,676,802 patients. Compared with non-Hispanic White (NHW) patients, non-Hispanic Black (NHB) and Hispanic patients had lower adjusted odds (aOR [95% confidence interval]) of receiving imaging for asthma (0.60 [0.56 to 0.63] NHB; 0.84 [0.79 to 0.89] Hispanic), bronchiolitis (0.84 [0.79 to 0.89] NHB; 0.93 [0.88 to 0.99] Hispanic), head injury (0.84 [0.80 to 0.88] NHB; 0.80 [0.76 to 0.84] Hispanic), headache (0.67 [0.63 to 0.72] NHB; 0.83 [0.78 to 0.88] Hispanic), and constipation (0.71 [0.67 to 0.74] NHB; 0.76 [0.72 to 0.80] Hispanic). NHB patients had lower odds (95% CI) of receiving imaging for afebrile seizures (0.89 [0.8 to 1.0]) and facial trauma (0.69 [0.60 to 0.80]). Hispanic patients had lower odds (95% CI) of imaging (0.57 [0.36 to 0.90]) and blood testing (0.82 [0.69 to 0.98]) for febrile seizures. NHB patients had higher odds (95% CI) of receiving steroids (1.11 [1.00 to 1.21]) and beta-agonists (1.38 [1.24 to 1.54]) for bronchiolitis compared with NHW patients. CONCLUSIONS NHW patients more frequently receive low-value imaging while NHB patients more frequently receive low-value medications for bronchiolitis. Our study demonstrates the differences in care across race and ethnicity extend to many services, including those of low value. These findings highlight the importance of greater understanding of the complex interaction of race and ethnicity with clinical practice.
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Affiliation(s)
- Joyce Li
- Division of Emergency Medicine, Boston Children's Hospital Harvard Medical School Boston Massachusetts USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Jennifer R. Marin
- Division of Pediatric Emergency Medicine UPMC Children's Hospital of Pittsburgh University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
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Khatri UG, Delgado MK, South E, Friedman A. Racial Disparities in the Management of Emergency Department Patients Presenting with Psychiatric Disorders. Ann Epidemiol 2022; 69:9-16. [DOI: 10.1016/j.annepidem.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/23/2021] [Accepted: 02/13/2022] [Indexed: 11/27/2022]
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