The associations of clinicians' implicit attitudes about race with medical visit communication and patient ratings of interpersonal care

Disparities in surgical outcomes for low socioeconomic status patients in Australia

Background

There are disparities in surgical outcomes for patients of low socioeconomic status globally, including in countries with universal healthcare systems. There is limited data on the impact of low socioeconomic status on surgical outcomes in Australia. This study examines surgical outcomes by both self‐reported unemployment and neighbourhood level socioeconomic status in Australia.

Methods

A retrospective administrative data review was conducted at a tertiary care centre over a 10‐year period (2008–2018) including all adult surgical patients. Multivariable logistic regression adjusting for year, age, sex and Charlson Comorbidity Index was performed.

Results

106 197 patients underwent a surgical procedure in the decade examined. The overall adverse event rates were mortality (1.13%), total postoperative complications (10.9%), failure to rescue (0.75%) and return to theatre (4.31%). Following multivariable testing, unemployed and low socioeconomic patients had a higher risk of postoperative mortality (OR 2.06 (1.50–2.82), OR 1.37 (1.15–1.64)), all complications (OR 1.43 (1.31–1.56), OR 1.21 (1.14–1.28)), failure to rescue (OR 2.03 (1.39–2.95), OR 1.38 (1.11–1.72)) and return to theatre (OR 1.42 (1.27–1.59), OR 1.24 (1.14–1.36)) (P < 0.005 for all).

Conclusions

Despite universal healthcare, there are disparities in surgical adverse events for patients of low socioeconomic status in Australia. Disparities in surgical outcomes can stem from three facets: a patient's access to healthcare (the severity of disease at the time of presentation), variation in perioperative care delivery, and social determinants of health. Further work is required to pinpoint why these disparities are present and to evaluate the impact of strategies that aim to reduce disparities.

Relationships between Key Functions of Patient-Provider Communication, Trust, and Motivation across White, African American, and Hispanic/Latino Patients with Asthma

Patient-provider communication is essential for providing effective care for asthma patients. However, little is known about key functions of communication and their relationships with outcomes in asthma patients across racial/ethnic groups. This study assessed asthma patients' perceptions of key functions of patient-provider communication, and examined associations between key functions, trust, and motivation across racial/ethnic groups. In this study, a sample of 470 US adults responded to an assessment of patient-provider communication, trust, and motivation through an electronically administered survey. Key functions of patient-provider communication included: exchanging information, responding to emotions, making decisions, enabling self-management, managing uncertainty, and fostering relationships. Results showed no differences in the mean scores of key functions of communication across racial/ethnic groups. The key function fostering relationships was positively associated with trust and motivation in both Whites and African Americans. However, the key function making decisions was associated with trust, and the key function managing uncertainty was associated with motivation only for Hispanic/Latinos. Results suggest different cultures may place different values on key functions of communication which may engender trust and motivation. Practical implications and suggestions for future research are discussed.

Diversity in Alzheimer's disease drug trials: The importance of eligibility criteria

INTRODUCTION

To generalize safety and efficacy findings, it is essential that diverse populations are well represented in Alzheimer's disease (AD) drug trials. In this review, we aimed to investigate participant diversity in disease-modifying AD trials over time, and the frequencies of participant eligibility criteria.

METHODS

A systematic review was performed using Medline, Embase, the Cochrane Library, and Clinicaltrials.gov, identifying 2247 records.

RESULTS

In the 101 included AD trials, participants were predominantly White (median percentage: 94.7%, interquartile range: 81.0-96.7%); and this percentage showed no significant increase or decrease over time (2001-2019). Eligibility criteria such as exclusion of persons with psychiatric illness (78.2%), cardiovascular disease (71.3%) and cerebrovascular disease (68.3%), obligated caregiver attendance (80.2%), and specific Mini-Mental State Examination scores (90.1%; no significant increase/decrease over time) may have led to a disproportionate exclusion of ethnoracially diverse individuals.

DISCUSSION

Ethnoracially diverse participants continue to be underrepresented in AD clinical trials. Several recommendations are provided to broaden eligibility criteria.

Novel Way to Improve Satisfaction, Comprehension, and Anxiety in Caregivers: A Randomized Trial Exploring the Use of Comprehensive, Illustrated Children's Books for Pediatric Surgical Populations

BACKGROUND

Surgery generates anxiety and stress, which can negatively impact informed consent and postoperative outcomes. This study assessed whether educational, illustrated children's books improve comprehension, satisfaction, and anxiety of caregivers in pediatric surgical populations.

METHODS

A prospective randomized trial was initiated at a tertiary care children's hospital. All patients ≤ 18 years old with caregiver and diagnosis of 1) uncomplicated appendicitis (English or Spanish speaking); 2) ruptured appendicitis; 3) pyloric stenosis; 4) need for gastrostomy tube; or 5) umbilical hernia were eligible. Conventional consent was obtained followed by completion of 17 validated survey questions addressing apprehension, satisfaction, and comprehension. Randomization (2:1) occurred after consent and before operative intervention with the experimental group (EG) receiving an illustrated comprehensive children's book outlining anatomy, pathophysiology, hospital course, and postoperative care. A second identical survey was completed before discharge. Primary outcomes were caregiver apprehension, satisfaction, and comprehension.

RESULTS

Eighty caregivers were included (55: EG, 25: control group [CG]). There were no significant differences in patient or caregiver demographics between groups. The baseline survey demonstrated no difference in comprehension, satisfaction, or apprehension between groups (all p values NS). After intervention, EG had significant improvement in 14 of 17 questions compared with CG (all p < 0.05). When tabulated by content, there was significant improvement in comprehension (p = 0.0009), satisfaction (p < 0.0001), and apprehension (p < 0.0001).

CONCLUSION

The use of illustrated educational children's books to explain pathophysiology and surgical care is a novel method to improve comprehension, satisfaction, and anxiety of caregivers. This could benefit informed consent, understanding, and postoperative outcomes.

Social Determinants of Health, Race, and Diabetes Population Health Improvement: Black/African Americans as a Population Exemplar

PURPOSE OF REVIEW

To summarize evidence of impact of social determinants of health (SDOH) on diabetes risk, morbidity, and mortality and to illustrate this impact in a population context.

RECENT FINDINGS

Key findings from the American Diabetes Association's scientific review of five SDOH domains (socioeconomic status, neighborhood and physical environment, food environment, health care, social context) are highlighted. Population-based data on Black/African American adults illustrate persisting diabetes disparities and inequities in the SDOH conditions in which this population is born, grows, lives, and ages, with historical contributors. SDOH recommendations from US national committees largely address a health sector response, including health professional education, SDOH measurement, and patient referral to services for social needs. Fewer recommendations address solutions for systemic racism and socioeconomic discrimination as root causes. SDOH are systemic, population-based, cyclical, and intergenerational, requiring extension beyond health care solutions to multi-sector and multi-policy approaches to achieve future population health improvement.

A Population Health Perspective on Racism and Racial Microaggressions

Racism, one of the social determinants of health, often goes unnoticed by those less affected by its pernicious effects. The lived social experience of race has been linked to significant physical and mental health disparities. Individually or together, we know that racism and discrimination are associated with poorer health of persons from racial minority groups as evidenced in higher rates of mortality, earlier onset of disease, greater severity and progression of disease and higher levels of comorbidity and impairment. These disparities are persistent over time and, although may lessen in degree, are evident at every level of income and education. This article provides a glimpse of the impact of racism on individuals and groups, with a focus on microaggressions as a subtle but pervasive form of racism, and how it is an underlying causative factor for health disparities.

Racism and oral health equity in the United States: Identifying its effects and providing future directions

While racial/ethnic oral health inequities have been documented for many years in the United States, the potential role of racism has not been examined until recently. In fact, the common practice has been to attribute racial/ethnic disparities in oral health to low socioeconomic position and/or the lack of access to care. In contrast, racism is considered a fundamental cause of a broad range of adverse health outcomes for racial/ethnic minorities. Emerging evidence on oral health suggests that racism can affect access to oral health and clinical decision-making by acting as a social determinant of health (SDoH). Specifically, SDoHs may affect access to quality dental care due to the lack of dental insurance, low dentist-population ratio in racial/ethnic minority communities and the lack of diversity in the dental profession. We describe potential mechanisms through which racism can affect important SDoHs that are essential to oral health equity, outline recommendations to mitigate its existing negative effects and propose interventions to minimize pathogenic effects of racism on oral health outcomes in the population.

From describing disparities to understanding why disparities exist: Anti-racist methods to support dental public health research

Racism is understudied in the oral health literature at the same time that race is overutilized as an explanatory factor in study design. Social and behavioral methodologies offer conceptual models that can be used to include racism in dental public health questions. In addition, interdisciplinary and mixed methods approaches allow for understanding racism as an underlying cause of social and health disparities and exploring solutions that address historical, institutional, social, political, and economic drivers of oral health inequity, while recognizing the limits of measuring racism quantitatively. In a collective acknowledgement of the limitations of conventional methods, there are new opportunities to explore how qualitative and mixed methods research can serve as drivers for both social justice and health equity, while building and sustaining a diverse research workforce that can better close these disparities and offer antiracist solutions to oral health inequities.

Women Veterans' Attrition from the VA Health Care System

PURPOSE

Patient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans' perspectives on why they left or continued to use VA health care.

METHODS

A sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use.

RESULTS

Fifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs.

CONCLUSIONS

Understanding the drivers of patients' decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.

Presence 5 for Racial Justice Workshop: Fostering Dialogue Across Medical Education to Disrupt Anti-Black Racism in Clinical Encounters

INTRODUCTION

Anti-Black racism has strong roots in American health care and medical education. While curricula on social determinants of health are increasingly common in medical training, curricula directly addressing anti-Black racism are limited. Existing frameworks like the Presence 5 framework for humanism in medicine can be adapted to develop a novel workshop that promotes anti-racism communication.

METHODS

We performed a literature review of anti-racism collections and categorized anti-racism communication practices using the Presence 5 framework to develop the Presence 5 for Racial Justice Workshop. Implementation included an introductory didactic, a small-group discussion, and a large-group debrief. Participants evaluated the workshop via an online survey, and we analyzed the resulting qualitative feedback.

RESULTS

A total of 17 participants took part in two workshops, with nine of the participants responding to the evaluation survey. Themes that emerged from survey responses included strengths of and improvements for the workshop structure (protected time for anti-racism discussion, dialogue between learners and faculty) and content (specific phrases and language, practicing self-reflection).

DISCUSSION

The workshop provides participants with a semistructured discussion around the five anti-racism communication practices. Barriers to implementation include incorporating the workshop into existing curricula and ensuring diverse learners. Barriers to evaluating the workshop include the low survey response rate. Recommendations to improve the workshop include using case-based discussion and varying the workshop structure according to institutional needs. Next steps include an implementation study to evaluate the acceptability, feasibility, and effectiveness of the workshop.

Acceptability and feasibility of video-based coaching to enhance clinicians' communication skills with patients

BACKGROUND

Despite a growing call to train clinicians in interpersonal communication skills, communication training is either not offered or is minimally effective, if at all. A critical need exists to develop new ways of teaching communication skills that are effective and mindful of clinician time pressures. We propose a program that includes real-time observation and video-based coaching to teach clinician communication skills. In this study, we assess acceptability and feasibility of the program using clinician interviews and surveys.

METHODS

The video-based coaching intervention targets five patient-centered communication behaviors. It uses trained communication coaches and live feed technology to provide coaching that is brief (less than 15 min), timely (same day) and theory-informed. Two coaches were trained to set up webcams and observe live video feeds of clinician visits in rooms nearby. As coaches watched and recorded the visit, they time stamped illustrative clips in real time. Video clips were a critical element of the program. During feedback sessions, coaches used video clips to promote discussion and self-reflection. They also used role play and guided practice techniques to enforce new tips. Clinicians included residents (n = 15), fellows (n = 4), attending physicians (n = 3), and a nurse practitioner (n = 1) at two primary care clinics in Houston, Texas. We administered surveys to clinicians participating in the program. The survey included questions on quality and delivery of feedback, and credibility of the coaches. We also interviewed clinicians following the intervention. We used rapid analysis to identify themes within the interviews.

RESULTS

Survey measures showed high feasibility and acceptability ratings from clinicians, with mean item scores ranging from 6.4 to 6.8 out of 7 points. Qualitative analysis revealed that clinicians found that 1) coaches were credible and supportive, 2) feedback was useful, 3) video-clips allowed for self-reflection, 4) getting feedback on the same day was useful, and 5) use of real patients preferred over standardized patients.

CONCLUSIONS

Video-based coaching can help clinicians learn new communication skills in a way that is clinician-centered, brief and timely. Our study demonstrates that real-time coaching using live feed and video technology is an acceptable and feasible way of teaching communication skills.

Interpersonal (mis)perceptions and (mis)predictions in patient-clinician interactions

Patient-clinician interactions require an interpersonal exchange of information, preferences, expectations, values, and priorities. Given the brief interaction patients and clinicians are allowed, many barriers to effective communication exist, resulting in patients and clinicians leaving an interaction with discordant perceptions of what has occurred and what is to come. We review literature on concordance and lack thereof, between patient and clinician perceptions, reasons why discordance may occur, how to decrease discordance as well as how dischordance impacts patient care and outcomes.

Racial/Ethnic Differences in Pediatric Emergency Department Wait Times

OBJECTIVES

Wait time for emergency care is a quality measure that affects clinical outcomes and patient satisfaction. It is unknown if there is racial/ethnic variability in this quality measure in pediatric emergency departments (PEDs). We aim to determine whether racial/ethnic differences exist in wait times for children presenting to PEDs and examine between-site and within-site differences.

METHODS

We conducted a retrospective cohort study for PED encounters in 2016 using the Pediatric Emergency Care Applied Research Network Registry, an aggregated deidentified electronic health registry comprising 7 PEDs. Patient encounters were included among all patients 18 years or younger at the time of the ED visit. We evaluated differences in emergency department wait time (time from arrival to first medical evaluation) considering patient race/ethnicity as the exposure.

RESULTS

Of 448,563 visits, median wait time was 35 minutes (interquartile range, 17-71 minutes). Compared with non-Hispanic White (NHW) children, non-Hispanic Black (NHB), Hispanic, and other race children waited 27%, 33%, and 12% longer, respectively. These differences were attenuated after adjusting for triage acuity level, mode of arrival, sex, age, insurance, time of day, and month [adjusted median wait time ratios (95% confidence intervals): 1.11 (1.10-1.12) for NHB, 1.12 (1.11-1.13) for Hispanic, and 1.05 (1.03-1.06) for other race children compared with NHW children]. Differences in wait time for NHB and other race children were no longer significant after adjusting for clinical site. Fully adjusted median wait times among Hispanic children were longer compared with NHW children [1.04 (1.03-1.05)].

CONCLUSIONS

In unadjusted analyses, non-White children experienced longer PED wait times than NHW children. After adjusting for illness severity, patient demographics, and overcrowding measures, wait times for NHB and other race children were largely determined by site of care. Hispanic children experienced longer within-site and between-site wait times compared with NHW children. Additional research is needed to understand structures and processes of care contributing to wait time differences between sites that disproportionately impact non-White patients.

Individual and Health Policy Factors Associated With Positive Heroin and Opioid Treatment Response: United States, 2018

Objectives. To identify client- and state-level factors associated with positive treatment response among heroin and opioid treatment episodes in the United States. Methods. We used national data from 46 states using the Treatment Episode Dataset‒Discharges (2018) to identify heroin and opioid treatment episodes (n = 162 846). We defined positive treatment response as a decrease in use between admission and discharge. We used multivariable regression, stratified by race/ethnicity, to identify demographic, pain-related, and state-level factors associated with positive treatment response. Results. Lower community distress was the strongest predictor of better treatment outcomes across all racial/ethnic groups, particularly among White and American Indian/Alaska Native episodes. A primary opioid of heroin was associated with worse outcomes among White and Hispanic episodes. Legislation limiting opioid dispensing was associated with better outcomes among Hispanic episodes. Buprenorphine availability was strongly associated with better outcomes among Black episodes. Conclusions. State-level variables, particularly community distress, had greater associations with positive treatment outcomes than client-level variables. Public Health Implications. Changes in state-level policies and increased resources directed toward areas of high community distress have the potential to improve opioid use disorder treatment and reduce racial/ethnic disparities in treatment outcomes. (Am J Public Health. 2022;112(S1):S66-S76. https://doi.org/10.2105/AJPH.2021.306503).

Negative Patient Descriptors: Documenting Racial Bias In The Electronic Health Record

Little is known about how racism and bias may be communicated in the medical record. This study used machine learning to analyze electronic health records (EHRs) from an urban academic medical center and to investigate whether providers' use of negative patient descriptors varied by patient race or ethnicity. We analyzed a sample of 40,113 history and physical notes (January 2019-October 2020) from 18,459 patients for sentences containing a negative descriptor (for example, resistant or noncompliant) of the patient or the patient's behavior. We used mixed effects logistic regression to determine the odds of finding at least one negative descriptor as a function of the patient's race or ethnicity, controlling for sociodemographic and health characteristics. Compared with White patients, Black patients had 2.54 times the odds of having at least one negative descriptor in the history and physical notes. Our findings raise concerns about stigmatizing language in the EHR and its potential to exacerbate racial and ethnic health care disparities.

A Call to Action: Promoting Diversity, Equity, and Inclusion in Parkinson's Research and Care

The current base of knowledge around Parkinson's disease has been assembled in partnership with a cohort of participants that does not resemble the diversity of people with the disease. This poor representation in research results in an incomplete picture of the disease and disparities in care. The Michael J. Fox Foundation has defined four major areas of action: 1) identifying barriers and solutions to research participation; 2) funding inclusive research with greater participant diversity; 3) building a clinician/researcher workforce committed to health equity; and 4) supporting a more holistic understanding of PD. While factors driving disparities, including broader societal challenges, are complex, it is imperative that the PD research, care, and patient communities move in a decisive and coordinated fashion to identify and implement strategies that advance treatments for everyone with PD and eliminate care inequities.

The Need for Psychedelic-Assisted Therapy in the Black Community and the Burdens of Its Provision

Psychedelic medicine is an emerging field that examines entheogens, psychoactive substances that produce non-ordinary states of consciousness (NOSC). 3,4-methylenedioxymethamphetamine (MDMA) is currently in phase-3 FDA clinical trials in the United States (US) and Canada to treat the symptoms of posttraumatic stress disorder (PTSD). MDMA is used in conjunction with manualized therapy, because of its effectiveness in reducing fear-driven stimuli that contribute to trauma and anxiety symptoms. In 2017, the FDA designated MDMA as a "breakthrough therapy," signaling that it has advantages in safety, efficacy, and compliance over available medication for the treatment of trauma-, stress-, and anxiety-related disorders such as PTSD. In the US and Canada, historical and contemporary racial mistreatment is frequently experienced by Black people via a variety of macro and micro insults. Such experiences trigger physiological responses of anxiety and fear, which are associated with chronically elevated stress hormone levels (e.g., cortisol and epinephrine), similar to levels documented among those diagnosed with an anxiety disorder. This paper will explore the benefits of entheogens within psychedelic assisted-therapy and their potential benefits in addressing the sequelae of pervasive and frequent negative race-based experiences and promoting healing and thriving among Black, Indigenous and other People of Color (BIPOC). The author(s) discuss the ethical responsibility for providing psychedelic-assisted therapy within a culturally competent provider framework and the importance of psychedelic researchers to recruit and retain BIPOC populations in research and clinical training.

Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs

Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient–clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers’ work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities.

What Do Placebo and Nocebo Effects Have to Do With Health Equity? The Hidden Toll of Nocebo Effects on Racial and Ethnic Minority Patients in Clinical Care

A placebo effect is a positive clinical response to non-specific elements of treatment with a sham or inert replica of a drug, device, or surgical intervention. There is considerable evidence that placebo effects are driven by expectation of benefit from the intervention. Expectation is shaped by a patient's past experience, observations of the experience of others, and written, verbal, or non-verbal information communicated during treatment. Not surprisingly, expectation in the clinical setting is strongly influenced by the attitude, affect, and communication style of the healthcare provider. While positive expectations can produce beneficial effects, negative information and experiences can lead to negative expectations, and consequently negative or nocebo effects. Key components identified and studied in the placebo and nocebo literature intersect with factors identified as barriers to quality care in the clinical setting for Black patients and other patients of color, including poor patient-clinician communication, medical mistrust, and perceived discrimination. Thus, in the context of discrimination and bias, the absence of placebo and presence of nocebo-generating influences in clinical settings could potentially reinforce racial and ethnic inequities in clinical outcomes and care. Healthcare inequities have consequences that ripple through the medical system, strengthening adverse short- and long-term outcomes. Here, we examine the potential for the presence of nocebo effects and absence of placebo effects to play a role in contributing to negative outcomes related to unequal treatment in the clinical encounter.

Implicit biases in healthcare: implications and future directions for gynecologic oncology

Health disparities have been found among patients with gynecologic cancers, with the greatest differences arising among groups based on racial, ethnic, and socioeconomic factors. Although there may be multiple social barriers that can influence health disparities, another potential influence may stem from healthcare system factors that unconsciously perpetuate bias toward patients who are racially and socioeconomically disadvantaged. More recent research suggested that providers hold these implicit biases (automatic and unconscious attitudes) for stigmatized populations with cancer, with emerging evidence for patients with gynecologic cancer. These implicit biases may guide providers' communication and medical judgments, which, in turn, may influence the patient's satisfaction with and trust in the provider. This narrative review consolidated the current research on implicit bias in healthcare, with a specific emphasis on oncology professionals, and identified future areas of research for examining and changing implicit biases in the field of gynecologic oncology.

Disparities in receipt of medications for opioid use disorder among pregnant women

Background: Medications for opioid use disorder (MOUD) improve outcomes for pregnant women and infants. Our primary aim was to examine disparities in maternal MOUD receipt by family sociodemographic characteristics. Methods: This retrospective cohort study included mother-infant dyads with Medicaid-covered deliveries in Tennessee from 2009 to 2016. First, we examined family sociodemographic characteristics - including race/ethnicity, rurality, mother's primary language and education level, and whether paternity was recorded in birth records - and newborn outcomes by type of maternal opioid use. Second, among pregnant women with OUD, we used logistic regression to measure disparities in receipt of MOUD by family sociodemographic characteristics including interactions between characteristics. Results: Our cohort from Medicaid-covered deliveries consisted of 314,965 mother-infant dyads, and 4.2 percent were exposed to opioids through maternal use. Among dyads with maternal OUD, MOUD receipt was associated with lower rates of preterm and very preterm birth. Logistic regression adjusted for family sociodemographic characteristics showed that pregnant women with OUD in rural versus urban areas (aOR: 0.66; 95% CI: 0.60-0.72) and who were aged ≥35 years versus ≤25 years (aOR: 0.75; 95% CI: 0.64-0.89) were less likely to have received MOUD. Families in which the mother's primary language was English (aOR: 2.47; 95% CI: 1.24-4.91) and paternity was recorded on the birth certificate (aOR: 1.30; 95% CI: 1.19-1.42) were more likely to have received MOUD. Regardless of high school degree attainment, non-Hispanic Black versus non-Hispanic White race was associated with lower likelihood of MOUD receipt. Hispanic race was associated with lower likelihood of MOUD receipt among women without a high school degree. Conclusions: Among a large cohort of pregnant women, we found disparities in receipt of MOUD among non-Hispanic Black, Hispanic, and rural pregnant women. As policymakers consider strategies to improve access to MOUD, they should consider targeted approaches to address these disparities.

Nonverbal Synchrony: An Indicator of Clinical Communication Quality in Racially-Concordant and Racially-Discordant Oncology Interactions

Objectives

The aim of this cross-sectional study was to apply a novel software to measure and compare levels of nonverbal synchrony, as a potential indicator of communication quality, in video recordings of racially-concordant and racially-discordant oncology interactions. Predictions include that the levels of nonverbal synchrony will be greater during racially-concordant interactions than racially-discordant interactions, and that levels of nonverbal synchrony will be associated with traditional measures of communication quality in both racially-concordant and racially-discordant interactions.

Design

This is a secondary observational analysis of video-recorded oncology treatment discussions collected from 2 previous studies.

Setting

Two National Cancer Institute-designated Comprehensive Cancer Centers and another large urban cancer center.

Participants

Participants from Study 1 include 161 White patients with cancer and 11 White medical oncologists. Participants from Study 2 include 66 Black/African-American patients with cancer and 17 non-Black medical oncologists. In both studies inclusion criteria for patients was a recent cancer diagnosis; in Study 2 inclusion criteria was identifying as Black/African American.

Main outcome measures

Nonverbal synchrony and communication quality.

Results

Greater levels of nonverbal synchrony were observed in racially-discordant interactions than in racially-concordant interactions. Levels of nonverbal synchrony were associated with indicators of communication quality, and these associations were more consistently found in racially-discordant interactions.

Conclusion

This study advances clinical communication and disparities research by successfully applying a novel approach capturing the unconscious nature of communication, and revealing differences in communication in racially-discordant and racially-concordant oncology interactions. This study highlights the need for further exploration of nonverbal aspects relevant to patient-physician interactions.

Correlation Between Pharmacy Students' Implicit Bias Scores, Explicit Bias Scores, and Responses to Clinical Cases

Objective. The purpose of this study was to identify the extent of implicit and explicit bias in a sample of pharmacy students and to determine whether there is an association between implicit bias, explicit bias, and responses to clinical cases.Methods. Investigators sent links to two online surveys to students at six US schools and colleges of pharmacy. In the first survey, students responded to two clinical cases. Students were presented with a picture of a White or Black patient with each clinical case. On the second survey, students indicated their level of racial implicit bias as assessed by the Harvard Implicit Association Test and their level of racial explicit bias. Pearson's correlation was used to determine the correlation between bias and responses to the clinical cases.Results. Three hundred fifty-seven first, second, and third year pharmacy students responded to both surveys (response rate 52%). The students who were presented with the picture of a Black patient rated the patient's pain and the reliability of the patient's family as higher than students presented with the picture of a White patient. Students had more negative implicit and explicit bias towards Black patients. Neither implicit nor explicit bias correlated with student responses to the clinical cases.Conclusion. Evidence of slight to moderate negative implicit bias and slight negative explicit bias towards Black patients was identified in this group of pharmacy students. Future studies that include a more representative population and heighten the stakes of the clinical scenario should be done to investigate a possible correlation between bias and clinical behaviors.

Women's experiences with person-centered family planning care: Differences by sociodemographic characteristics

Objective

Person-centered contraceptive care is associated with positive reproductive health outcomes. Our objective was to analyze patients’ ratings on the newly developed Person-Centered Contraceptive Counseling scale (PCCC) to provide distributions for a nationally representative population and to assess differences by sociodemographic characteristics.

Study design

Using data from 2017 to 2019 National Survey of Family Growth (NSFG), we analyzed ratings across the four PCCC items among 2242 women who received contraceptive counseling in the past year. Items measured patients’ reports of how providers respected them, let them describe their contraceptive preferences, took their preferences seriously, and adequately informed them about their options. We studied each PCCC item individually as well as the combined scale, distinguishing between ratings of “excellent” versus lower ratings. Bivariate and multivariate logistic regression models assessed how patients’ characteristics (age, race/ethnicity and English proficiency, sexual orientation, income, and parity) and provider type were associated with the likelihood of experiencing person-centered care.

Results

The majority of women (59%–69%) reported that their family planning provider was “excellent” across the four PCCC items and just over half (51%) reported “excellent” on all items. In multivariate analyses, having a lower income, Black race, non-heterosexual identity, and Hispanic ethnicity combined with low English proficiency were associated with lower PCCC ratings.

Conclusions

In a nationally representative sample, the PCCC captured variation in women's experiences with person-centered family planning care by sociodemographic characteristics. Findings highlight the need for contraceptive counseling that centers on clients’ preferences and experiences, particularly for patients who belong to groups experiencing health inequities.

Implications

Person-centered care is a key component of high-quality family planning services. This analysis highlights sociodemographic disparities in person-centered care by analyzing PCCC ratings. Findings show the value of this new health care performance measure and affirm the need for family planning care that centers individuals' preferences and lived experiences.

Learning to Practice Compassionate Care: Medical Students Discuss Their Most Memorable Lessons

Compassion in interactions between physicians and patients can have a therapeutic effect independent of the technical medical treatment provided. However, training physicians to effectively communicate compassion is challenging. This study explores how medical students experienced training focused on interacting with patients by examining students’ reports of particularly memorable lessons. Six focus groups were conducted with medical students (total n = 48) in their fourth year of training. We report on responses from students to the question, “What was the most memorable lesson you have learned about interacting with patients?” Students discussed lessons aimed at patient-centered physical navigation, interpersonal navigation, and perspective taking. Concerns were raised that navigation techniques felt inauthentic and that perspective taking was too time consuming to be sustainable in actual practice. While perspective-taking exercises should motivate medical students to treat every patient with dignity by demonstrating the complexity of others’ lives, if students assume that full understanding is a prerequisite to delivery of compassionate care, they may dismiss explicit techniques of patient-centered care as inauthentic and perceive compassion and efficiency as mutually exclusive.

Nurse bias and nursing care disparities related to patient characteristics: A scoping review of the quantitative and qualitative evidence

INTRODUCTION

Investigations of healthcare workers' implicit attitudes about patient characteristics and differences in delivery of healthcare due to bias are increasingly common. However, there is a gap in our understanding of nurse-specific bias and care disparities.

AIMS

To identify (a) the types of available evidence, (b) key factors and relationships identified in the evidence and (c) knowledge gaps related to nurse bias (nurse attitudes or beliefs towards a patient characteristic) and nursing care disparities (healthcare disparities related specifically to nursing care).

METHODS

Authors completed a scoping review using the Joanne Briggs Institute method and PRISMA-SCR checklist. Five databases were searched. After screening, 215 research reports were included and examined. Data were extracted from research reports and assessed for thematic patterns and trends across multiple characteristics.

RESULTS

Nurse bias and/or care disparity investigations have become increasingly common over the 38-year span of included reports. Multiple patient characteristics have been investigated, with the most common being race and/or ethnicity, gender and age. Twenty-nine of 215 studies identified a potential relationship between nurse bias regarding a characteristic and nursing care of individuals with that characteristic. Of these studies, 27 suggested the bias was associated with a negative disparate impact on nursing care. Only 12 reports included evaluating an intervention designed to reduce nurse bias or nursing care-related healthcare disparities.

CONCLUSIONS

Despite increasing research focus on individual bias and disparities in healthcare, the accumulated knowledge regarding nurses has not significantly advanced past a descriptive, exploratory level. Nor has there been a consistent focus on the role of nurses, who represent the largest component of the professional healthcare workforce.

RELEVANCE TO CLINICAL PRACTICE

National and international codes of ethics for nurses require provision of care according to individual, unique patient need, disregarding bias and incorporating patient characteristics into their plan of care.

Race and Ethnicity and Cardiometabolic Risk Profile: Disparities Across Income and Health Insurance in a National Sample of US Adults

CONTEXT

Income and health insurance are important social determinants of cardiovascular disease (CVD) and may explain much racial/ethnic variation in CVD burden. However, racial/ethnic disparities in cumulative cardiometabolic (CMB) risk profile by insurance type and income level have not been studied on a national scale.

OBJECTIVES

To test the hypothesis that racial/ethnic minorities experience greater CMB burden at each income level and insurance type than non-Hispanic Whites (NHW).

SETTING

This study used nationally representative data from the National Health Interview Survey (NHIS).

DESIGN

Observational (cross-sectional).

PARTICIPANTS

In total, 134661 (weighted N = 197780611) adults, 18 years or older, from the 2013-2017 NHIS.

PRIMARY OUTCOME

CMB risk profile.

INTERVENTION/ANALYSIS

Age-adjusted prevalence of optimal, average, and poor CMB risk profile-defined respectively as self-report of 0, 1-2, and 3 or more risk factors of diabetes, hypertension, obesity, or hypercholesterolemia-was examined for NHW, non-Hispanic Blacks (NHB), and Hispanics. Multivariable ordinal logistic regression models were used to test the association between race and ethnicity and CMB profile overall and separately by household income level and insurance type.

RESULTS

Overall, 15% of NHB and 11% of Hispanics experienced poor CMB risk profile, compared with 9% for NHW. In fully adjusted models, NHB and Hispanics, respectively had nearly 25%-90% and 10%-30% increased odds of poor CMB profile across insurance types and 45%-60% and 15%-30% increased odds of poor CMB profile across income levels, relative to NHW. The observed disparities were widest for the Medicare group (NHB: OR = 1.90; Hispanics: OR = 1.31) and highest-income level (NHB: OR = 1.62).

CONCLUSIONS

Racial/ethnic minorities experience poor CMB profile at each level of income and insurance. These findings point to the need for greater investigation of unmeasured determinants of minority cardiovascular (CV) health, including structural racism and implicit bias in CV care.

[Testimonial injustice against people with mental disorders in health care. A conceptual and ethical analysis]

Menschen mit psychischer Erkrankung sterben statistisch gesehen früher als die Allgemeinbevölkerung. Ein Grund hierfür ist, dass sie eine schlechtere somatische Gesundheitsversorgung erhalten. Wir argumentieren, dass ableistische Netzwerke sozialer Bedeutung zu einer Abwertung der epistemischen Kompetenz von Menschen mit psychischer Erkrankung führen. Diese Abwertung kann mit dem Konzept der testimonialen Ungerechtigkeit erfasst werden. Testimoniale Ungerechtigkeit bezeichnet das ungerechtfertigte Herabstufen der Glaubwürdigkeit einer*s Sprecher*in aufgrund eines Vorurteils gegen ihre*seine soziale Identität. Wir analysieren ethische und epistemische Folgen testimonialer Ungerechtigkeit als wichtige Ursachen der schlechteren Gesundheitsversorgung von Menschen mit psychischer Erkrankung. Testimoniale Ungerechtigkeit kann zu medizinischen Behandlungsfehlern führen und für Betroffene schwerwiegende gesundheitliche Folgen nach sich ziehen. Zudem kann sie zu einem Vertrauensverlust von Menschen mit psychischer Erkrankung in das Gesundheitssystem führen. Daher trägt testimoniale Ungerechtigkeit zur strukturellen Diskriminierung von Menschen mit psychischer Erkrankung bei. Vor diesem Hintergrund diskutieren wir, wie die somatische Gesundheitsversorgung unter ethischen Gesichtspunkten verbessert werden kann.

Are You Really the Doctor? Physician Experiences with Gendered Microaggressions from Patients

Background: In contrast to physician implicit bias toward patients, bias and microaggressions from patients toward physicians have received comparatively less attention. Materials and Methods: We captured physician experiences of gendered microaggressions from patients by conducting a mixed-methods survey-based study of physicians at a single academic health care institution in May 2019. A quantitative portion assessed the frequency of gendered microaggressions (microaggression experiences [ME] score) and the association with measures of perceived impacts (job satisfaction, burnout, perceived career impacts, behavioral modifications). A one-tailed Wilcoxon rank sum test compared distributional frequencies of microaggressions by gender, and by gender and race. Chi-square tests measured the associations between gendered microaggressions and perceived impacts. Welch two-sample t-tests assessed differences in ME scores by rank and specialty. Linear regression assessed the association of ME scores and job satisfaction/burnout. A qualitative portion solicited anecdotal experiences, analyzed by inductive thematic analysis. Results: There were 297 completed surveys (response rate 27%). Female physicians experienced a significantly higher frequency of gendered microaggressions (p < 0.001) compared with male physicians. Microaggressions were significantly associated with job satisfaction (chi-square 6.83, p = 0.009), burnout (chi-square 8.76, p = 0.003), perceived career impacts (chi-square 18.67, p < 0.001), and behavioral modifications (chi-square 19.96, p < 0.001). Trainees experienced more microaggressions (p = 0.009) and burnout (p = 0.009) than faculty. Higher ME scores predicted statistically significant increases in burnout (p < 0.0001) and reduced job satisfaction (p = 0.02). Twelve microaggressions themes emerged from the qualitative responses, including role questioning and assumption of inexperience. The frequency of microaggressions did not vary significantly by race; however, qualitative responses described race as a factor. Conclusions: Physicians experience gendered microaggressions from patients, which may influence job satisfaction, burnout, career perceptions, and behavior. Future research may explore the multidirectionality of microaggressions and tools for responding at the individual and institutional level.

Diversity of the physician workforce: Specialty choice decisions during medical school

Background

Despite efforts to increase the overall diversity of the medical student body, some medical specialties have a less diverse applicant pool based on both gender and race than would be expected based on medical graduate demographics.

Objectives

To identify whether women and Underrepresented in Medicine (URiM) medical students have baseline differences in their career interests or if their career plans change more during medical school when compared to men and non-URIM students.

Methods

Secondary data analyses of all medical students who applied through ERAS from 2005–2010 was conducted. Binary logistic regression models with the response being a planned career in one of four medical specialties (internal medicine, pediatrics, OB/GYN, and general surgery/surgical specialties) at medical school entry and graduation. Regression models included demographics, student attitudes, debt, academic metrics, and medical school experiences.

Results

Comparatively, women were less likely to be interested in internal medicine and surgery and more interested in pediatrics and OB/GYN at matriculation. URiM students expressed more interest in OB/GYN and surgery when starting medical school. At graduation, women were less likely to plan for internal medicine and surgery and were more interested in pursuing OB/GYN and pediatrics. URiM students were more likely to plan for a career in internal medicine and less likely to choose pediatrics.

Conclusions

From matriculation to graduation, women have relatively stable preferences regarding planned medical specialties. In contrast, URiM students’ specialty plans shifted over time among the four specialties, with variation in preferences occurring between matriculation and graduation.

A Review of Disparities in Cardiac Rehabilitation: EVIDENCE, DRIVERS, AND SOLUTIONS

PURPOSE

Cardiac rehabilitation (CR) has been shown to improve functional status, quality of life, and recurrent cardiovascular disease (CVD) events. Despite its demonstrated compelling benefits and guideline recommendation, CR is underutilized, and there are significant disparities in CR utilization particularly by race, ethnicity, sex, and socioeconomic status. The purpose of this review is to summarize the evidence and drivers of these disparities and recommend potential solutions.

METHODS

In this review, key studies documenting disparities in CR referrals, enrollment, and completion are discussed. Additionally, potential mechanisms for these disparities are summarized and strategies are reviewed for addressing them.

SUMMARY

There is a wealth of literature demonstrating disparities among racial and ethnic minorities, women, those with lower income and education attainment, and those living in rural and dense urban areas. However, there was minimal focus on how the social determinants of health contribute to the observed disparities in CR utilization in many of the studies reviewed. Interventions such as automatic referrals, inpatient liaisons, mitigation of economic barriers, novel delivery mechanisms, community partnerships, and health equity metrics to incentivize health care organizations to reduce care disparities are potential solutions.

The use of person-centered language in scientific research articles focusing on opioid use disorder

BACKGROUND

Opioid Use Disorder (OUD) affects approximately 1% of the population. Despite the prevalence of OUD, it remains a highly stigmatized disorder. Using person-centered language (PCL) - and thereby emphasizing the significance of the person rather than their diagnosis - is a potential strategy to reduce stigma in medical research related to addiction. Thus, we aimed to determine adherence to PCL in OUD-related publications according to the American Medical Association's guidelines.

METHODS

We performed a systematic search for articles published between January 1, 2016 through December 31, 2020 using the PubMed database. Articles were randomized and screened until we reached 300 articles that met inclusion criteria. Three-hundred articles were screened to meet this goal. Articles were then screened for non-PCL terms, determined a priori.

RESULTS

The majority (240/300; 80 %) of OUD-related publications were not adherent to the AMA guidelines on PCL. Additionally, the use of emotional language (i.e. suffer, afflicted, etc.) was employed in 48 % (145/300) of articles. Stigmatizing terminology was found in 73 % (218/300) of the OUD related articles in this study. Our study demonstrated a statistically significant correlation between senior author affiliation and adherence to reporting guidelines (i.e., PRISMA, STROBE, etc.).

CONCLUSION

A majority of OUD-related publications are not adherent to AMA guidelines on PCL. Language used in these publications is often repeated and replicated in medical education and clinical practice, which directly impacts patient-provider relationships. PCL-adherent language is a tool that both medical researchers and clinicians can use to combat stigma that individuals with OUD may experience.

Early Racial/Ethnic Disparities in Continuous Glucose Monitor Use in Pediatric Type 1 Diabetes

Racial-ethnic disparities in technology use have been described in children with type 1 diabetes (T1D). It is not known whether these emerge early in disease management. This single-center retrospective study examined disparities in continuous glucose monitor (CGM) initiation and durability in the first-year after diagnosis of T1D in children. Of 345 eligible children, 46% started CGM within their first year. In non-Hispanic white (NHW) children, 51% started using CGM versus 28% of non-Hispanic black (NHB) children (P = 0.006). After stratifying by commercial/government insurance, a proxy for socioeconomic status, this difference persisted among those with commercial insurance. One-year post-CGM initiation, 96% (125/130) of NHW children were using CGM versus 73% (11/15) of NHB children (P = 0.003). Disparities in CGM use emerge early in care of children with T1D, with lower rates of initiation and sustained use of CGM in NHB children. Strategies addressing causes of these disparities should begin early in T1D management.

Is physician implicit bias associated with differences in care by patient race for metastatic cancer-related pain?

Rationale

Implicit racial bias affects many human interactions including patient-physician encounters. Its impact, however, varies between studies. We assessed the effects of physician implicit, racial bias on their management of cancer-related pain using a randomized field experiment.

Methods

We conducted an analysis of a randomized field experiment between 2012 and 2016 with 96 primary care physicians and oncologists using unannounced, Black and White standardized patients (SPs)who reported uncontrolled bone pain from metastatic lung cancer. We assessed implicit bias using a pain-adaptation of the race Implicit Association Test. We assessed clinical care by reviewing medical records and prescriptions, and we assessed communication from coded transcripts and covert audiotapes of the unannounced standardized patient office visits. We assessed effects of interactions of physicians’ implicit bias and SP race with clinical care and communication outcomes. We conducted a slopes analysis to examine the nature of significant interactions.

Results

As hypothesized, physicians with greater implicit bias provided lower quality care to Black SPs, including fewer renewals for an indicated opioid prescription and less patient-centered pain communication, but similar routine pain assessment. In contrast to our other hypotheses, physician implicit bias did not interact with SP race for prognostic communication or verbal dominance. Analysis of the slopes for the cross-over interactions showed that greater physician bias was manifested by more frequent opioid prescribing and greater discussion of pain for White SPs and slightly less frequent prescribing and pain talk for Black SPs with the opposite effect among physicians with lower implicit bias. Findings are limited by use of an unvalidated, pain-adapted IAT.

Conclusion

Using SP methodology, physicians’ implicit bias was associated with clinically meaningful, racial differences in management of uncontrolled pain related to metastatic lung cancer. There is favorable treatment of White or Black SPs, depending on the level of implicit bias.

Association Between English Proficiency and Timing of Analgesia Administration After Surgery

BACKGROUND

Pediatric patients from families with limited English proficiency (LEP) are at risk for health care disparities. We examined timeliness of analgesic administration in pediatric postoperative patients with a limb fracture from LEP versus non-LEP families.

METHODS

This was a retrospective cohort study of children aged 1 year to <18 years of age, hospitalized to the general inpatient floor after surgical correction of single limb fractures between July 2016 and July 2019 were eligible. Patients whose consent was in a non-English language or for whom an interpreter was used were classified as from LEP families. The primary outcome was time to first analgesia. Secondary outcomes included time to first opioid, proportion with any analgesia and opioid analgesia, and number of pain assessments. Associations between LEP and outcomes were tested by using χ² tests, Kaplan-Meier plots, and Cox proportional hazards models.

RESULTS

We examined 306 patients, of whom 59 (19%) were from LEP families. Children in LEP families were significantly less likely to receive any analgesia (86.4% vs 96.8%, P ≤ .01) and experienced longer time to first analgesia in unadjusted (hazard ratio = 0.68, 95% confidence interval: 0.50-0.92) and adjusted analyses (hazard ratio = 0.68, 95% confidence interval: 0.50-0.94). There was no significant association between LEP and time to first opioid, proportion given opioid analgesia, or number of pain assessments.

CONCLUSION

Hospitalized children from LEP families experience a longer time to analgesia administration after surgery. The mechanisms that lead to these differences in care must be identified so that interventions can be designed to address them.

We are part of the problem: the role of children's hospitals in addressing health inequity

Racism is an ongoing public health crisis that undermines health equity for all children in hospitals across our nation. The presence and impact of institutionalized racism contributes to health inequity and is under described in the medical literature. In this review, we focus on key interdependent areas to foster inclusion, diversity, and equity in Children's Hospitals, including 1) promotion of workforce diversity 2) provision of anti-racist, equitable hospital patient care, and 3) prioritization of academic scholarship focused on health equity research, quality improvement, medical education, and advocacy. We discuss the implications for clinical and academic practice.Plain Language Summary: Racism in Children's Hospitals harms children. We as health-care providers and hospital systems are part of the problem. We reviewed the literature for the best ways to foster inclusion, diversity, and equity in hospitals. Hospitals can be leaders in improving child health equity by supporting a more diverse workforce, providing anti-racist patient care, and prioritizing health equity scholarship.

Theory-Informed Clinical Practice: How Physical Therapists Can Use Fundamental Interventions to Address Social Determinants of Health

The American Physical Therapy Association's Vision Statement for the profession is guided by principles of innovation, access, equity, and advocacy, and calls on physical therapists to stretch their influence beyond the walls of the clinic and the individuals they treat. Access and equity are problems that span multiple health care professions and entities; yet, addressing social determinants of health is a paradigm shift that clinicians need continued support to achieve. This article has 2 objectives: (1) to define the Fundamental Cause Theory and the Socioecological Model within the context of physical therapy in order to promote best clinical practice, and (2) to apply the concept of "fundamental interventions" in clinical practice to mitigate the negative impact of downstream effects of social determinants of health across levels of the Socioecological Model-individual, interpersonal, institutional, community, and societal. This theoretical lens provides the conceptual framework necessary for physical therapists to think creatively about ways to change their practice in their own contexts to impact the life of individual patients and transform the movement health of society.

IMPACT

As health care providers, physical therapists have a responsibility to make every effort to meet the needs of their patients and optimize movement health in society; yet significant structural and systemic barriers often prevent patients from reaching their fullest potential. Clinicians can no longer subscribe to a narrow scope of practice focused on individual attainment of therapy goals. This Perspective discusses Fundamental Cause Theory and the Socioecological Model theoretical frameworks that can help physical therapists develop, test, and implement functional interventions to address the needs of society as a whole.

Underrepresented Populations in Pediatric Epilepsy Surgery

As awareness of pediatric epilepsy increases, accompanied by advancements in technology and research, it is important to identify certain types of patients that are overlooked for surgical management of epilepsy. Identifying these populations will allow us to study and elucidate the factors contributing to the underutilization and/or delayed application of surgical interventions. Demographically, African-American and Hispanic patients, as well as patients of certain Asian ethnicities, have relatively lower rates of undergoing epilepsy surgery than non-Hispanic and white patients. Among patients with epilepsy, those with higher odds of seizure-freedom following surgery are more likely to be referred for surgical evaluation by their neurologists, with the most common diagnosis being lesional focal epilepsy. However, patients with multifocal or generalized epilepsy, genetic etiologies, or normal (non-lesional) brain magnetic resonance imaging (MRI) are less likely be to referred for evaluation for resective surgery. With an increasing number of high-quality imaging modalities to help localize the epileptogenic zone as well as new techniques for both curative and palliative epilepsy surgery, there are very few populations of patients and/or types of epilepsy that should be precluded from evaluation to determine the suitability of epilepsy surgery. Ultimately, a clearer understanding of the populations who are underrepresented among those considered for epilepsy surgery, coupled with further study of the underlying reasons for this trend, will lead to less disparity in access to this critical treatment among patients with epilepsy.

Implicit racial bias among medical graduates and students by an IAT measure: a systematic review and meta-analysis

INTRODUCTION

Racial implicit bias is an unconscious response and behavior that affects interpersonal interactions and clinical decision-making.

AIMS

We attempted to meta-analyze the scores of implicit association test (IAT) to estimate pooled quantity of implicit racial bias among medical graduates and students METHODS: As far as we know, our study is the first systematic-based meta-analysis estimating the pooled score of implicit racial bias among physicians and medical students. Keywords were searched in Scopus, Web of Science, Google Scholar, PubMed, Science Direct, Cochrane, MEDLINE, Wiley online library, and ProQuest databases from 2011 since 2021. The IAT's pooled score estimates through a fixed-effect meta-analysis using STATA 15. Also, I² statistic was used to determine heterogeneity across the articles.

RESULTS

Out of 1177 articles, 29 studies entered to analysis. The pooled score of IAT among physicians and medical students was 0.28 (95% CI 0.13 to 0.43) and 0.35 (95% CI 0.03 to 0.67), respectively. The racial bias score of physician ranged from -0.12 to 0.62. While score of implicit association test for medical student ranged from -0.01 to 1.29.

CONCLUSION

Our meta-analysis revealed that there was an implicit anti-black attitude among physicians and medical students, but the size of this implicit racial bias was small. Although the level of racial bias in physicians and medical students was low, it could be reduced to the lowest level through informative programs and training in ways to control implicit attitudes.

Thrombolytic Refusal Over Telestroke

Background

Tissue plasminogen activator (tPA) refusal is 4%-6% for acute ischemic stroke (AIS) in the emergency department. Telestroke (TS) has increased the use of tPA for AIS but is accompanied by barriers in communication that can affect tPA consent. We characterized the incidence of tPA refusal in our TS network and its associated reasons.

Methods

Patients with AIS who were offered tPA within 4.5 hours from symptom onset according to American Heart Association guidelines were identified within our Lone Star Stroke Consortium Telestroke Registry from September 2015 to December 2018. We compared baseline characteristics and clinical outcomes between patients who refused tPA and patients who accepted tPA.

Results

Among the 1,242 patients who qualified for tPA and were offered treatment, 8% refused tPA. Female and non-Hispanic Black patients and patients with a prior history of stroke were more likely to decline tPA. Patients who refused tPA presented with a lower NIHSS and were associated with a final diagnosis of stroke mimic (odds ratio [OR] 0.23; 95% confidence interval [CI] 0.15-0.36). Good outcome (90-day modified Rankin Scale 0-2) was the same among patients who received tPA and those who refused (OR 0.80; 95% CI 0.42-1.54). The most common reasons for refusal were rapidly improving and mild/nondisabling symptoms and concern for potential side effects.

Conclusion

tPA refusal over TS is comparable to previously reported rates; there was no difference in outcomes among patients who received tPA compared with those who refused. Sex and racial differences associated with an increased tPA refusal warrant further investigation in efforts to achieve equity/parity in tPA decisions.

Implicit Bias and Caring for Diverse Populations: Pediatric Trainee Attitudes and Gaps in Training

The objective of this study was to determine the attitudes, skill level, and preferred educational interventions of pediatric residents related to implicit bias and caring for diverse patient populations. A cross-sectional survey of pediatric residents at a single, large urban residency program was utilized. Surveys were completed by 88 (55%) residents who were 69% female and 35% non-White or mixed race. Almost all residents felt that it was very or extremely important to receive training on health disparities, diverse patient populations, and implicit bias. Self-assessment of skill level revealed that residents felt confident in areas often covered by cultural competency curricula, such as interpreter use, but were less confident in other areas. The top 3 areas identified for further training included implicit bias, working with transgender and gender nonconforming patients, and weight bias. For the majority of diversity and bias-related skills, prior training was significantly correlated with higher skill level (P < .05).

Racial and ethnic disparities in bronchiolitis management in freestanding children's hospitals

OBJECTIVE

Variation in bronchiolitis management by race and ethnicity within emergency departments (EDs) has been described in single-center and prospective studies, but large-scale assessments across EDs and inpatient settings are lacking. Our objective is to describe the association between race and ethnicity and bronchiolitis management across 37 U.S. freestanding children's hospitals from 2015 to 2018.

METHODS

Using the Pediatric Health Information System, we analyzed ED and inpatient visits from November 2015 to November 2018 of children with bronchiolitis 3 to 24 months old. Rates of use for specific diagnostic tests and therapeutic measures were compared across the following race/ethnicity categories: 1) non-Hispanic White (NHW), 2) non-Hispanic Black (NHB), 3) Hispanic, and 4) other. The subanalyses of ED patients only and children < 1 year old were performed. Mixed-effect logistic regression was performed to compare the adjusted odds of receiving specific test/treatment using NHW children as the reference group.

RESULTS

A total of 134,487 patients met inclusion criteria (59% male, 28% NHB, 26% Hispanic). Adjusted analysis showed that NHB children had higher odds of receiving medication associated with asthma (odds ratio [OR] = 1.27, 95% confidence interval [CI] = 1.22 to 1.32) and lower odds of receiving diagnostic tests (blood cultures, complete blood counts, viral testing, chest x-rays; OR = 0.78, 95% CI = 0.75 to 0.81) and antibiotics (OR = 0.58, 95% CI = 0.52 to 0.64) than NHW children. Hispanic children had lower odds of receiving diagnostic testing (OR = 0.94, 95% CI = 0.90 to 0.98), asthma-associated medication (OR = 0.92, 95% CI = 0.88 to 0.96), and antibiotics (OR = 0.74, 95% CI = 0.66 to 0.82) compared to NHW children.

CONCLUSION

NHB children more often receive corticosteroid and bronchodilator therapies; NHW children more often receive antibiotics and chest radiography. Given that current guidelines generally recommend supportive care with limited diagnostic testing and medical intervention, these findings among NHB and NHW children represent differing patterns of overtreatment. The underlying causes of these patterns require further investigation.

Racial Disparities in Developmental Delay Diagnosis and Services Received in Early Childhood

BACKGROUND AND OBJECTIVE

Racial disparities in diagnosis and receipt of services for early childhood developmental delay (DD) are well known but studies have had difficulties distinguishing contributing patient, healthcare system, and physician factors from underlying prevalence. We examine rates of physician diagnoses of DD by preschool and kindergarten entry controlling for a child's objective development via scoring on validated developmental assessment along with other child characteristics.

METHODS

We used data from the preschool and kindergarten entry waves of the Early Childhood Longitudinal Study, Birth Cohort. Dependent variables included being diagnosed with DD by a medical provider and receipt of developmental services. Logistic regression models tested whether a child's race was associated with both outcomes during preschool and kindergarten while controlling for the developmental assessments, as well as other contextual factors.

RESULTS

Among 7950 children, 6.6% of preschoolers and 7.5% of kindergarteners were diagnosed with DD. Of preschool children with DD, 66.5% were receiving developmental services, while 69.1% of kindergarten children with DD were receiving services. Children who were Black, Asian, spoke a primary language other than English and had no health insurance were less likely to be diagnosed with DD despite accounting for cognitive ability. Black and Latinx children were less likely to receive services.

CONCLUSIONS

Racial minority children are less likely to be diagnosed by their pediatric provider with DD and less likely to receive services despite accounting for a child's objective developmental assessment. The pediatric primary care system is an important target for interventions to reduce these disparities.

The intersection of race and opioid use disorder treatment: A quantitative analysis

INTRODUCTION

Racial health inequities exist in the United States. Racial minorities and whites have different health care experiences and health outcomes. Past studies examined this relationship for health care treatment, but additional research on whether and how race affects treatment for opioid use disorder (OUD) is needed. Based on systematic racism theory, this study examines the relationship between race and OUD treatment in three ways, representing three different phases in the treatment process: referral source for treatment, whether the treatment plan includes medications for OUD (MOUD), and reason for discharge.

METHODS

This study examines the relationship between race and treatment for OUD. The study uses data from the 2013 and 2017 Treatment Episode Data Set Discharges (TEDS-D) dataset to run logistical and multinomial regression models.

RESULTS

This study found that a relationship between race and treatment for OUD exists in all three areas that we examined. Specifically, this study found that being a minority was associated with a decreased likelihood of being referred to treatment by a medical professional, a decreased likelihood of having MOUD as part of the treatment plan (although the opposite was true in 2013), and a decreased likelihood of leaving treatment because the treatment episode was complete.

CONCLUSION

Policymakers should use these findings to develop policy interventions for OUD that recognize the systematic racism that exists rather than our current colorblind policies.