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

Qualitative Analysis of Student Pharmacists' Reflections of Harvard's Race Implicit Association Test

BACKGROUND AND PURPOSE

Identify and analyze pharmacy students' perceptions about their own implicit racial biases.

EDUCATIONAL ACTIVITY AND SETTING

First year pharmacy students (n = 97) enrolled in a Pharmacy Practice course completed a test, Harvard Race Implicit Association Test (IAT), for homework to uncover their unconscious black-white racial bias. All students then wrote at least one paragraph reflecting on if they agreed or disagreed with their results and why. At the beginning of class, students were given a brief survey to capture their IAT results and demographic information. Retrospectively and following Institutional Review Board approval, pharmacy students' reflections were subjected to thematic analysis with the assistance of NVivo 10 and descriptive analyses were completed of their demographic info.

FINDINGS

Out of the 97 students enrolled in this course, all completed the self-reflection. But only 90 completed the survey. From those that completed the survey, 54% (N = 49) self-identified as women. The average age was 22.6 years old. Most of the students (77%) identified themselves as White Non-Hispanic. Six percent (N = 5) identified as Black. Most students (66%) reported that their results from the Race IAT indicated some level of preference for European Americans; 13% of the students reported some level of preference for African-Americans. All students' reflections were categorized by their agreement or lack of agreement with their implicit association test results. Those that agreed with their results cited family, friends, and community contributing to their implicit biases. Students who did not agree with their results were subcategorized as denying their results, believing that their implicit association did not affect their behavior, or believing that the Race IAT was invalid.

DISCUSSION/SUMMARY

Many pharmacy students were found to be unaware of their implicit biases and some do not believe that these biases will negatively affect the treatment of others. Pharmacy curricula should be developed to provide adequate self-awareness training and space in the curriculum so students can challenge these unconscious beliefs.

Racial variations in extracorporeal membrane oxygenation use following congenital heart surgery

OBJECTIVES

Previous studies demonstrate racial and ethnic disparities among children undergoing congenital heart surgery. Extracorporeal membrane oxygenation (ECMO) is used to support critically ill children after congenital heart surgery and improve survival. Thus, racial or ethnic variations in postoperative ECMO use following congenital heart surgery may be associated with racial/ethnic disparities in hospital survival.

METHODS

All children in the Pediatric Health Information Systems dataset undergoing congenital heart surgery from 2004 to 2015 were examined. Multivariable, multinomial regression models examining hospital survival without ECMO use, survival after ECMO, death after ECMO, and death without ECMO support were constructed.

RESULTS

Of 130,860 congenital cardiac surgery patients, 95.4% survived to hospital discharge without requiring ECMO support, whereas 1.3% survived after ECMO support, 1.3% died after ECMO support, and 1.9% died without receiving ECMO support. After adjustment for other covariates, black patients (odds ratio, 1.22; 95% confidence interval [CI], 1.05-1.42) and patients of other race (odds ratio, 1.36; 95% CI, 1.17-1.58) were at increased odds of mortality compared with white patients. In multivariable multinomial models, black patients had increased risk of death without ECMO support (relative risk, 1.31; 95% CI, 1.11-1.56). Patients of other race (relative risk, 1.37; 95% CI, 1.10-1.69) and governmental insurance (relative risk, 1.24; 95% CI, 1.12-1.37) were also at increased risk of death without ECMO.

CONCLUSIONS

Black children and children of other race are at increased odds of mortality after congenital heart surgery. These disparities can be traced to variations in ECMO utilization across racial/ethnic groups.

The Actual Versus Idealized Self: Exploring Responses to Feedback About Implicit Bias in Health Professionals

PURPOSE

Implicit bias can adversely affect health disparities. The implicit association test (IAT) is a prompt to stimulate reflection; however, feedback about bias may trigger emotions that reduce the effectiveness of feedback interventions. Exploring how individuals process feedback about implicit bias may inform bias recognition and management curricula. The authors sought to explore how health professionals perceive the influence of the experience of taking the IAT and receiving their results.

METHOD

Using constructivist grounded theory methodology, the authors conducted semistructured interviews with 21 pediatric physicians and nurses at the Schulich School of Medicine and Dentistry, Western University, Ontario, Canada, from September 2015 to November 2016 after they completed the mental illness IAT and received their result. Data were analyzed using constant comparative procedures to work toward axial coding and development of an explanatory theory.

RESULTS

When provided feedback about their implicit attitudes, participants described tensions between acceptance and justification, and between how IAT results relate to idealized and actual personal and professional identity. Participants acknowledged desire for change while accepting that change is difficult. Most participants described the experience of taking the IAT and receiving their result as positive, neutral, or interesting.

CONCLUSIONS

These findings contribute to emerging understandings of the relationship between emotions and feedback and may offer potential mediators to reconcile feedback that reveals discrepancies between an individual's actual and idealized identities. These results suggest that reflection informed by tensions between actual and aspirational aspects of professional identity may hold potential for implicit bias recognition and management curricula.

Changes in medical student implicit attitudes following a health equity curricular intervention

PURPOSE

This study assessed the: (1) effect of an LGBTQI + health equity curriculum (eQuality) on implicit attitudes among first (M1) and second year (M2) medical students and (2) utility of dedicated time to explore implicit bias.

METHOD

Implicit biases were assessed at baseline using implicit association tests (IAT) for all M2s and a random sample of first years (M1A). These students were then debriefed on strategies to mitigate bias. Following eQuality, all M1 and M2s completed post-intervention IATs. The remaining first years (M1B) were then debriefed. Paired sample t-tests assessed differences between pre/post. Independent sample t-tests assessed differences in post-IATs between M1 groups.

RESULTS

IATs indicated preferences for "Straight," "White," and "Thin" at both pre and post. M2s demonstrated statistically significant improvements pre to post for sexuality (p = 0.01) and race (p = 0.03). There were significant differences in post-intervention IAT scores between M1As who received the IAT and debriefing prior to eQuality and M1Bs for sexuality (p = 0.002) and race (p = 0.046). There were no significant changes for weight.

CONCLUSION

eQuality reduced implicit preference for "Straight" and "White." Differences in M1 post-intervention IAT scores between groups suggest dedicating time to debrief implicit attitudes enhances bias mitigation.

Barriers to medication adherence in asthma: The importance of culture and context

OBJECTIVE

Significant disparities exist in asthma outcomes. Racial and ethnic minorities have lower controller medication adherence, which may contribute to differences in asthma morbidity between minority and non-minority groups. The objective of this review is to identify individual, patient-provider communication, and systems issues that contribute to this pattern of medication underuse and to discuss potential strategies for intervention.

DATA SOURCES

Data were gathered from numerous sources, including reports of pharmacy and medical records, observational studies, and trials.

STUDY SELECTIONS

Studies analyzed factors contributing to patterns of asthma medication adherence that differ by race and ethnicity.

RESULTS

There is clear evidence of underuse of asthma controller medications among racial and ethnic minorities in prescription receipt, prescription initiation, and medication use once obtained. Individual factors such as medication beliefs and depressive symptoms play a role. Provider communication is also relevant, including limited discussion of complementary and alternative medicine use, difficulties communicating with patients and caregivers with limited English proficiency, and implicit biases regarding cultural differences. Systems issues (eg, insurance status, cost) and social context factors (eg, exposure to violence) also present challenges. Culturally informed strategies that capitalize on patient strengths and training providers in culturally informed communication strategies hold promise as intervention approaches.

CONCLUSION

Disparities in controller medication use are pervasive. Identifying the sources of these disparities is a critical step toward generating intervention approaches to enhance disease management among the groups that bear the greatest asthma burden.

Ethnic bias and clinical decision-making among New Zealand medical students: an observational study

BACKGROUND

Health professional racial/ethnic bias may impact on clinical decision-making and contribute to subsequent ethnic health inequities. However, limited research has been undertaken among medical students. This paper presents findings from the Bias and Decision-Making in Medicine (BDMM) study, which sought to examine ethnic bias (Māori (indigenous peoples) compared with New Zealand European) among medical students and associations with clinical decision-making.

METHODS

All final year New Zealand (NZ) medical students in 2014 and 2015 (n = 888) were invited to participate in a cross-sectional online study. Key components included: two chronic disease vignettes (cardiovascular disease (CVD) and depression) with randomized patient ethnicity (Māori or NZ European) and questions on patient management; implicit bias measures (an ethnicity preference Implicit Association Test (IAT) and an ethnicity and compliant patient IAT); and, explicit ethnic bias questions. Associations between ethnic bias and clinical decision-making responses to vignettes were tested using linear regression.

RESULTS

Three hundred and two students participated (34% response rate). Implicit and explicit ethnic bias favoring NZ Europeans was apparent among medical students. In the CVD vignette, no significant differences in clinical decision-making by patient ethnicity were observed. There were also no differential associations by patient ethnicity between any measures of ethnic bias (implicit or explicit) and patient management responses in the CVD vignette. In the depression vignette, some differences in the ranking of recommended treatment options were observed by patient ethnicity and explicit preference for NZ Europeans was associated with increased reporting that NZ European patients would benefit from treatment but not Māori (slope difference 0.34, 95% CI 0.08, 0.60; p = 0.011), although this was the only significant finding in these analyses.

CONCLUSIONS

NZ medical students demonstrated ethnic bias, although overall this was not associated with clinical decision-making. This study both adds to the small body of literature internationally on racial/ethnic bias among medical students and provides relevant and important information for medical education on indigenous health and ethnic health inequities in New Zealand.

Medical Students' Implicit Bias and the Communication of Norms in Medical Education

ISSUE

Medical educators should consider how institutional norms influence medical students' perceptions of implicit bias. Understanding normative structures in medical education can shed light on why this influence is associated with students' resistance to implicit bias.

EVIDENCE

Extant research across diverse fields of study uncovers and theorizes layers of norms and normative systems and how they are related to ethical behavior. This review bridges the fields of communication, bioethics, and medical education, constructing an organized foundation and common language by which researchers can build effective educational interventions. First, the nature and effects of implicit bias are described. Second, the nature of normative systems in medical education is explicated. Concepts from the fields of education and communication are transferred to medical education. Third, the structure of the communication of norms in medical education is revealed, through theoretical research in bioethics and empirical medical education research.

IMPLICATIONS

Recommendations are provided for medical educators to improve activities intended to encourage reflection on implicit bias. These recommendations include reframing educational activities as endeavors in "personal" development and uncovering and transforming those normative structures that encourage resistance to implicit bias.

A Framework for Integrating Implicit Bias Recognition Into Health Professions Education

Existing literature on implicit bias is fragmented and comes from a variety of fields like cognitive psychology, business ethics, and higher education, but implicit-bias-informed educational approaches have been underexplored in health professions education and are difficult to evaluate using existing tools. Despite increasing attention to implicit bias recognition and management in health professions education, many programs struggle to meaningfully integrate these topics into curricula. The authors propose a six-point actionable framework for integrating implicit bias recognition and management into health professions education that draws on the work of previous researchers and includes practical tools to guide curriculum developers. The six key features of this framework are creating a safe and nonthreatening learning context, increasing knowledge about the science of implicit bias, emphasizing how implicit bias influences behaviors and patient outcomes, increasing self-awareness of existing implicit biases, improving conscious efforts to overcome implicit bias, and enhancing awareness of how implicit bias influences others. Important considerations for designing implicit-bias-informed curricula-such as individual and contextual variables, as well as formal and informal cultural influences-are discussed. The authors also outline assessment and evaluation approaches that consider outcomes at individual, organizational, community, and societal levels. The proposed framework may facilitate future research and exploration regarding the use of implicit bias in health professions education.

Exploring the Association of Healthcare Worker Race and Occupation with Implicit and Explicit Racial Bias

BACKGROUND

Racial bias is associated with suboptimal healthcare treatment for minorities. Research focuses on bias among physicians rather than non-physician healthcare staff (e.g., receptionists). Patients spend considerable amounts of time with non-physician staff. Therefore, we investigate differences in implicit and explicit racial bias by healthcare staff race and occupation using the Implicit Association Test and Modern Racism Scale, respectively.

METHODS

Staff (n = 107) were recruited using the Alabama based Primary Care Research Coalition. Occupation was categorized into "medical doctors/registered nurses" (MD/RN) and "non-MD/RN" (e.g., receptionists).

RESULTS

Implicit bias scores were higher among whites compared with blacks (0.62, -0.04, respectively; p < 0.01). Among whites, non-MD/RNs demonstrated more pro-white implicit bias compared with MD/RNs (0.67, 0.44, respectively; p < 0.01). Whites had higher explicit bias scores than blacks (17.7, 12.3, respectively; p < 0.01).

CONCLUSION

Non-MD/RNs should not be overlooked for cultural competency training, and efforts are needed to reduce racial bias among healthcare workers identified as having higher levels of bias.

Partnering around cancer clinical trials (PACCT): study protocol for a randomized trial of a patient and physician communication intervention to increase minority accrual to prostate cancer clinical trials

BACKGROUND

Cancer clinical trials are essential for testing new treatments and represent state-of-the-art cancer treatment, but only a small percentage of patients ever enroll in a trial. Under-enrollment is an even greater problem among minorities, particularly African Americans, representing a racial/ethnic disparity in cancer care. One understudied cause is patient-physician communication, which is often of poor quality during clinical interactions between African-American patients and non-African-American physicians. Partnering Around Cancer Clinical Trials (PACCT) involves a transdisciplinary theoretical model proposing that patient and physician individual attitudes and beliefs and their interpersonal communication during racially discordant clinical interactions influence outcomes related to patients' decisions to participate in a trial. The overall goal of the study is to test a multilevel intervention designed to increase rates at which African-American and White men with prostate cancer make an informed decision to participate in a clinical trial.

METHODS/DESIGN

Data collection will occur at two NCI-designated comprehensive cancer centers. Participants include physicians who treat men with prostate cancer and their African-American and White patients who are potentially eligible for a clinical trial. The study uses two distinct research designs to evaluate the effects of two behavioral interventions, one focused on patients and the other on physicians. The primary goal is to increase the number of patients who decide to enroll in a trial; secondary goals include increasing rates of physician trial offers, improving the quality of patient-physician communication during video recorded clinical interactions in which trials may be discussed, improving patients' understanding of trials offered, and increasing the number of patients who actually enroll. Aims are to 1) determine the independent and combined effects of the two interventions on outcomes; 2) compare the effects of the interventions on African-American versus White men; and 3) examine the extent to which patient-physician communication mediates the effect of the interventions on the outcomes.

DISCUSSION

PACCT has the potential to identify ways to increase clinical trial rates in a diverse patient population. The research can also improve access to high quality clinical care for African American men bearing the disproportionate burden of disparities in prostate and other cancers.

TRIAL REGISTRATION

Clinical Trials.gov registration number: NCT02906241 (September 8, 2016).

Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students

BACKGROUND

Implicit and explicit bias among providers can influence the quality of healthcare. Efforts to address sexual orientation bias in new physicians are hampered by a lack of knowledge of school factors that influence bias among students.

OBJECTIVE

To determine whether medical school curriculum, role modeling, diversity climate, and contact with sexual minorities predict bias among graduating students against gay and lesbian people.

DESIGN

Prospective cohort study.

PARTICIPANTS

A sample of 4732 first-year medical students was recruited from a stratified random sample of 49 US medical schools in the fall of 2010 (81% response; 55% of eligible), of which 94.5% (4473) identified as heterosexual. Seventy-eight percent of baseline respondents (3492) completed a follow-up survey in their final semester (spring 2014).

MAIN MEASURES

Medical school predictors included formal curriculum, role modeling, diversity climate, and contact with sexual minorities. Outcomes were year 4 implicit and explicit bias against gay men and lesbian women, adjusted for bias at year 1.

KEY RESULTS

In multivariate models, lower explicit bias against gay men and lesbian women was associated with more favorable contact with LGBT faculty, residents, students, and patients, and perceived skill and preparedness for providing care to LGBT patients. Greater explicit bias against lesbian women was associated with discrimination reported by sexual minority students (b = 1.43 [0.16, 2.71]; p = 0.03). Lower implicit sexual orientation bias was associated with more frequent contact with LGBT faculty, residents, students, and patients (b = -0.04 [-0.07, -0.01); p = 0.008). Greater implicit bias was associated with more faculty role modeling of discriminatory behavior (b = 0.34 [0.11, 0.57); p = 0.004).

CONCLUSIONS

Medical schools may reduce bias against sexual minority patients by reducing negative role modeling, improving the diversity climate, and improving student preparedness to care for this population.

Health Disparities in Patients with Pulmonary Arterial Hypertension: A Blueprint for Action. An Official American Thoracic Society Statement

BACKGROUND

Health disparities have a major impact in the quality of life and clinical care received by minorities in the United States. Pulmonary arterial hypertension (PAH) is a rare cardiopulmonary disorder that affects children and adults and that, if untreated, results in premature death. The impact of health disparities in the diagnosis, treatment, and clinical outcome of patients with PAH has not been systematically investigated.

OBJECTIVES

The specific goals of this research statement were to conduct a critical review of the literature concerning health disparities in PAH, identify major research gaps and prioritize direction for future research.

METHODS

Literature searches from multiple reference databases were performed using medical subject headings and text words for pulmonary hypertension and health disparities. Members of the committee discussed the evidence and provided recommendations for future research.

RESULTS

Few studies were found discussing the impact of health disparities in PAH. Using recent research statements focused on health disparities, the group identified six major study topics that would help address the contribution of health disparities to PAH. Representative studies in each topic were discussed and specific recommendations were made by the group concerning the most urgent questions to address in future research studies.

CONCLUSIONS

At present, there are few studies that address health disparities in PAH. Given the potential adverse impact of health disparities, we recommend that research efforts be undertaken to address the topics discussed in the document. Awareness of health disparities will likely improve advocacy efforts, public health policy and the quality of care of vulnerable populations with PAH.

The impact of Black cancer patients' race-related beliefs and attitudes on racially-discordant oncology interactions: A field study

OBJECTIVE

Both physician and patient race-related beliefs and attitudes are contributors to racial healthcare disparities, but only the former have received substantial research attention. Using data from a study conducted in the Midwestern US from 2012 to 2014, we investigated whether 114 Black cancer patients' existing race-related beliefs and attitudes would predict how they and 18 non-Black physicians (medical oncologists) would respond in subsequent clinical interactions.

METHOD

At least two days before interacting with an oncologist for initial discussions of treatment options, patients completed measures of perceived past discrimination, general mistrust of physicians, and suspicion of healthcare systems; interactions were video-recorded. Measures from each interaction included patients' verbal behavior (e.g., level of verbal activity), patients' evaluations of physicians (e.g., trustworthiness), patients' perceptions of recommended treatments (e.g., confidence in treatment), physicians' evaluations of patient personal attributes (e.g., intelligence) and physicians' expectations for patient treatment success (e.g., adherence).

RESULTS

As predicted, patients' race-related beliefs and attitudes differed in their associations with patient and physician responses to the interactions. Higher levels of perceived past discrimination predicted more patient verbal activity. Higher levels of mistrust also predicted less patient positive affect and more negative evaluations of physicians. Higher levels of suspicion predicted more negative evaluations of physicians and recommended treatments. Stronger patient race-related attitudes were directly or indirectly associated with lower physician perceptions of patient attributes and treatment expectations.

CONCLUSION

Results provide new evidence for the role of Black patients' race-related beliefs and attitudes in racial healthcare disparities and suggest the need to measure multiple beliefs and attitudes to identify these effects.

Medicaid insurance as primary payer predicts increased mortality after total hip replacement in the state inpatient databases of California, Florida and New York

STUDY OBJECTIVE

To confirm the relationship between primary payer status as a predictor of increased perioperative risks and post-operative outcomes after total hip replacements.

DESIGN

Retrospective cohort study.

SETTING

Administrative database study using 2007-2011 data from California, Florida, and New York from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.

PATIENTS

295,572 patients age≥18years old who underwent total hip replacement with non-missing insurance data were collected, using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses and procedures code (ICD-9-CM code 81.51).

INTERVENTIONS

Patients underwent total hip replacement.

MEASUREMENTS

Patients were cohorted by insurance type as either Medicare, Medicaid, Uninsured, Other, and Private Insurance. Demographic characteristics and comorbidities were compared. Unadjusted rates of in-hospital mortality, postoperative complications, LOS, 30-day, and 90-day readmission status were compared. Adjusted odds ratios were calculated for our outcomes using multivariate linear and logistic regression models fitted to our data.

MAIN RESULTS

Medicaid patients incurred a 125% increase in the odds of in-hospital mortality compared to those with Private Insurance (OR 2.25, 99% CI 1.01-5.01). Medicaid payer status was associated with the highest statistically significant adjusted odds of mortality, any complication (OR, 1.26), cardiovascular complications (OR, 1.37), and infectious complications (OR, 1.66) when compared with Private Insurance. Medicaid patients had the highest statistically significant adjusted odds of 30-day (OR, 1.63) and 90-day readmission (OR, 1.58) and the longest adjusted LOS.

CONCLUSIONS

We found higher unadjusted rates and risk adjusted odds ratios of postoperative mortality, morbidity, LOS, and readmissions for patients with Medicaid insurance as compared to patients with Private Insurance. Our study shows that primary payer status serves as a predictor of perioperative risks and that primary payer status should be viewed as a peri-operative risk factor.

A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making

OBJECTIVES

Disparities in diagnosis and treatment of racial minorities exist in the emergency department (ED). A better understanding of how physician implicit (unconscious) bias contributes to these disparities may help identify ways to eliminate such racial disparities. The objective of this systematic review was to examine and summarize the evidence on the association between physician implicit racial bias and clinical decision making.

METHODS

Based on PRISMA guidelines, a structured electronic literature search of PubMed, CINAHL, Scopus, and PsycINFO databases was conducted. Eligible studies were those that: 1) included physicians, 2) included the Implicit Association Test as a measure of implicit bias, 3) included an assessment of physician clinical decision making, and 4) were published in peer-reviewed journals between 1998 and 2016. Articles were reviewed for inclusion by two independent investigators. Data extraction was performed by one investigator and checked for accuracy by a second investigator. Two investigators independently scored the quality of articles using a modified version of the Downs and Black checklist.

RESULTS

Of the 1,154 unique articles identified in the initial search, nine studies (n = 1,910) met inclusion criteria. Three of the nine studies involved emergency providers including residents, attending physicians, and advanced practice providers. The majority of studies used clinical vignettes to examine clinical decision making. Studies that included emergency medicine (EM) providers had vignettes relating to treatment of acute myocardial infarction, pain, and pediatric asthma. An implicit preference favoring white people was common across providers, regardless of specialty. Two of the nine studies found evidence of a relationship between implicit bias and clinical decision making; one of these studies included EM providers. This one study found that EM and internal medicine residents who demonstrated an implicit preference for white individuals were more likely to treat white patients and not black patients with thrombolysis for myocardial infarction. Evidence from the two studies reporting a relationship between physician implicit racial bias and decision making was low in quality.

CONCLUSIONS

The current literature indicates that although many physicians, regardless of specialty, demonstrate an implicit preference for white people, this bias does not appear to impact their clinical decision making. Further studies on the impact of implicit racial bias on racial disparities in ED treatment are needed.

Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care

BACKGROUND

Major joint replacement surgical procedures are common, elective procedures with a care episode that includes both inpatient readmissions and postoperative emergency department (ED) visits. Inpatient readmissions are well studied; however, to our knowledge, little is known about ED visits following these procedures. We sought to characterize 30-day ED visits following a major joint replacement surgical procedure.

METHODS

We used administrative records from California, Florida, and New York, from 2010 through 2012, to identify adults undergoing total knee and hip arthroplasty. Factors associated with increased risk of an ED visit were estimated using hierarchical regression models controlling for patient variables with a fixed hospital effect. The main outcome was an ED visit within 30 days of discharge.

RESULTS

Among the 152,783 patients who underwent major joint replacement, 5,229 (3.42%) returned to the inpatient setting and 8,883 (5.81%) presented to the ED for care within 30 days. Among ED visits, 17.94% had a primary diagnosis of pain and 25.75% had both a primary and/or a secondary diagnosis of pain. Patients presenting to the ED for subsequent care had more comorbidities and were more frequently non-white with public insurance relative to those not returning to the ED (p < 0.001). There was a significantly increased risk (p < 0.05) of isolated ED visits with regard to type of insurance when patients with Medicaid (odds ratio [OR], 2.28 [95% confidence interval (CI), 2.04 to 2.55]) and those with Medicare (OR, 1.38 [95% CI, 1.29 to 1.47]) were compared with patients with private insurance and with regard to race when black patients (OR, 1.38 [95% CI, 1.25 to 1.53]) and Hispanic patients (OR, 1.12 [95% CI, 1.03 to 1.22]) were compared with white patients. These increases in risk were stronger for isolated ED visits for patients with a pain diagnosis.

CONCLUSIONS

ED visits following an elective major joint replacement surgical procedure were numerous and most commonly for pain-related diagnoses. Medicaid patients had almost double the risk of an ED or pain-related ED visit following a surgical procedure. The future of U.S. health-care insurance coverage expansions are uncertain; however, there are ongoing attempts to improve quality across the continuum of care. It is therefore essential to ensure that all patients, particularly vulnerable populations, receive appropriate postoperative care, including pain management.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pain and pharmacologic pain management in long-stay nursing home residents

Previous studies estimate that >40% of long-stay nursing home (NH) residents experience persistent pain, with 20% of residents in pain receiving no analgesics. Strengthened NH surveyor guidance and improved pain measures on the Minimum Data Set 3.0 were introduced in March 2009 and October 2010, respectively. This study aimed to provide estimates after the important initiatives of (1) prevalence and correlates of persistent pain; and (2) prevalence and correlates of untreated or undertreated persistent pain. We identified 1,387,405 long-stay residents in U.S. NHs between 2011 and 2012 with 2 Minimum Data Set assessments 90 days apart. Pain was categorized as persistent (pain on both assessments), intermittent (pain on either assessment), or none. Pharmacologic pain management was classified as untreated pain (no scheduled or as needed medications received) or potentially undertreated (no scheduled received). Modified Poisson models adjusting for resident clustering within NHs provided adjusted prevalence ratios (APRs) estimates and 95% confidence intervals (CIs). The prevalence of persistent and intermittent pain was 19.5% and 19.2%, respectively, but varied substantially by age, sex, race and ethnicity, cognitive impairment, and cancer. Of residents in persistent pain, 6.4% and 32.0% were untreated and undertreated, respectively. Racial and ethnic minorities (non-Hispanic blacks vs whites, APR = 1.19, 95% CI: 1.13-1.25) and severely cognitively impaired residents (severe vs no/mild APR = 1.51, 95% CI: 1.44-1.57) had an increased prevalence of untreated and undertreated pain. One in 5 NH residents has persistent pain. Although this estimate is greatly improved, many residents may be undertreated. The disturbing disparities in untreated and undertreated pain need to be addressed.

A successful model for longitudinal community-engaged health research: the 2040 Partners for Health Student Program

Introduction

Community-based participatory research [CBPR] is an emerging approach to collaborative research aimed at creating locally effective and sustainable interventions. The 2040 Partners for Health student program was developed as a unique model of longitudinal CBPR. Analysis of this program and its components illuminates both the challenges and the opportunities inherent in community engagement.

Methods

The program rests on a foundation of a community-based, non-profit organization and a supportive academic university centre. Inter-professional health students and community members of underserved populations work together on different health projects by employing an adapted CBPR methodology. Three successful examples of sustainable CBPR projects are briefly described.

Results

The three projects are presented as primary outcomes resulting from this model. Benefits and challenges of the model as an approach to community-engaged research are discussed as well as secondary benefits of student participation.

Conclusion

The 2040 Partners for Health student program represents a successful model of CBPR, illuminating common challenges and reiterating the profound value of community-engaged research.

Racial and Ethnic Variation in Pediatric Cardiac Extracorporeal Life Support Survival

OBJECTIVES

Previous studies have suggested an association between nonwhite race and poor outcomes in small subsets of cardiac surgery patients who require extracorporeal life support. This study aims to examine the association of race/ethnicity with mortality in pediatric patients who receive extracorporeal life support for cardiac support.

DESIGN

Retrospective analysis of registry data.

SETTING

Prospectively collected multi-institutional registry data.

SUBJECTS

Data from all North American pediatric patients in the Extracorporeal Life Support International Registry who received extracorporeal life support for cardiac support between 1998 and 2012 were analyzed. Multivariate regression models were constructed to examine the association between race/ethnicity and hospital mortality, adjusting for demographics, diagnosis, pre-extracorporeal life support care, extracorporeal life support variables, and extracorporeal life support-related complications.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 7,106 patients undergoing cardiac extracorporeal life support, the majority of patients were of white race (56.9%) with black race (16.7%), Hispanic ethnicity (15.8%), and Asian race (2.8%) comprising the other major race/ethnic groups. The mortality rate was 53.9% (n = 3,831). After adjusting for covariates, multivariate analysis identified black race (relative risk = 1.10; 95% CI, 1.04-1.16) and Hispanic ethnicity (relative risk = 1.08; 95% CI, 1.02-1.14) as independent risk factors for mortality.

CONCLUSIONS

Black race and Hispanic ethnicity are independently associated with mortality in children who require cardiac extracorporeal life support.

The Role of Bias by Emergency Department Providers in Care for American Indian Children

BACKGROUND

American Indian children have high rates of emergency department (ED) use and face potential discrimination in health care settings.

OBJECTIVE

Our goal was to assess both implicit and explicit racial bias and examine their relationship with clinical care.

RESEARCH DESIGN

We performed a cross-sectional survey of care providers at 5 hospitals in the Upper Midwest. Questions included American Indian stereotypes (explicit attitudes), clinical vignettes, and the Implicit Association Test. Two Implicit Association Tests were created to assess implicit bias toward the child or the parent/caregiver. Differences were assessed using linear and logistic regression models with a random effect for study site.

RESULTS

A total of 154 care providers completed the survey. Agreement with negative American Indian stereotypes was 22%-32%. Overall, 84% of providers had an implicit preference for non-Hispanic white adults or children. Older providers (50 y and above) had lower implicit bias than those middle aged (30-49 y) (P=0.01). American Indian children were seen as increasingly challenging (P=0.04) and parents/caregivers less compliant (P=0.002) as the proportion of American Indian children seen in the ED increased. Responses to the vignettes were not related to implicit or explicit bias.

CONCLUSIONS

The majority of ED care providers had an implicit preference for non-Hispanic white children or adults compared with those who were American Indian. Provider agreement with negative American Indian stereotypes differed by practice and respondents' characteristics. These findings require additional study to determine how these implicit and explicit biases influence health care or outcomes disparities.

Implicit Bias in Pediatric Academic Medicine

OBJECTIVE

Despite known benefits of diversity, certain racial/ethnic groups remain underrepresented in academic pediatrics. Little research exists regarding unconscious racial attitudes among pediatric faculty responsible for decisions on workforce recruitment and retention in academia. This study sought to describe levels of unconscious racial bias and perceived barriers to minority recruitment and retention among academic pediatric faculty leaders.

METHODS

Authors measured unconscious racial bias in a sample of pediatric faculty attending diversity workshops conducted at local and national meetings in 2015. A paper version of the validated Implicit Association Test (IAT) measured unconscious racial bias. Subjects also reported perceptions about minority recruitment and retention.

RESULTS

Of 68 eligible subjects approached, 58 (85%) consented and completed the survey with IAT. Of participants, 83% had leadership roles and 93% were involved in recruitment. Participants had slight pro-white/anti-black bias on the IAT (M = 0.28, SD = 0.49). There were similar IAT scores among participants in leadership roles (M = 0.33, SD = 0.47) and involved in recruitment (M = 0.28, SD = 0.43). Results did not differ when comparing participants in local workshops to the national workshop (n = 36, M = 0.29, SD = 0.40 and n = 22, M = 0.27, SD = 0.49 respectively; p = 0.88). Perceived barriers to minority recruitment and retention included lack of minority mentors, poor recruitment efforts, and lack of qualified candidates.

CONCLUSIONS

Unconscious pro-white/anti-black racial bias was identified in this sample of academic pediatric faculty and leaders. Further research is needed to examine how unconscious bias impacts decisions in academic pediatric workforce recruitment. Addressing unconscious bias and perceived barriers to minority recruitment and retention represent opportunities to improve diversity efforts.

Implicit bias in healthcare professionals: a systematic review

Background

Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender. This review examines the evidence that healthcare professionals display implicit biases towards patients.

Methods

PubMed, PsychINFO, PsychARTICLE and CINAHL were searched for peer-reviewed articles published between 1st March 2003 and 31st March 2013. Two reviewers assessed the eligibility of the identified papers based on precise content and quality criteria. The references of eligible papers were examined to identify further eligible studies.

Results

Forty two articles were identified as eligible. Seventeen used an implicit measure (Implicit Association Test in fifteen and subliminal priming in two), to test the biases of healthcare professionals. Twenty five articles employed a between-subjects design, using vignettes to examine the influence of patient characteristics on healthcare professionals’ attitudes, diagnoses, and treatment decisions. The second method was included although it does not isolate implicit attitudes because it is recognised by psychologists who specialise in implicit cognition as a way of detecting the possible presence of implicit bias. Twenty seven studies examined racial/ethnic biases; ten other biases were investigated, including gender, age and weight. Thirty five articles found evidence of implicit bias in healthcare professionals; all the studies that investigated correlations found a significant positive relationship between level of implicit bias and lower quality of care.

Discussion

The evidence indicates that healthcare professionals exhibit the same levels of implicit bias as the wider population. The interactions between multiple patient characteristics and between healthcare professional and patient characteristics reveal the complexity of the phenomenon of implicit bias and its influence on clinician-patient interaction. The most convincing studies from our review are those that combine the IAT and a method measuring the quality of treatment in the actual world. Correlational evidence indicates that biases are likely to influence diagnosis and treatment decisions and levels of care in some circumstances and need to be further investigated. Our review also indicates that there may sometimes be a gap between the norm of impartiality and the extent to which it is embraced by healthcare professionals for some of the tested characteristics.

Conclusions

Our findings highlight the need for the healthcare profession to address the role of implicit biases in disparities in healthcare. More research in actual care settings and a greater homogeneity in methods employed to test implicit biases in healthcare is needed.

Comparison of Physician Implicit Racial Bias Toward Adults Versus Children

BACKGROUND AND OBJECTIVES

The general population and most physicians have implicit racial bias against black adults. Pediatricians also have implicit bias against black adults, albeit less than other specialties. There is no published research on the implicit racial attitudes of pediatricians or other physicians toward children. Our objectives were to compare implicit racial bias toward adults versus children among resident physicians working in a pediatric emergency department, and to assess whether bias varied by specialty (pediatrics, emergency medicine, or other), gender, race, age, and year of training.

METHODS

We measured implicit racial bias of residents before a pediatric emergency department shift using the Adult and Child Race Implicit Association Tests (IATs). Generalized linear models compared Adult and Child IAT scores and determined the association of participant demographics with Adult and Child IAT scores.

RESULTS

Among 91 residents, we found moderate pro-white/anti-black bias on both the Adult (mean = 0.49, standard deviation = 0.34) and Child Race IAT (mean = 0.55, standard deviation = 0.37). There was no significant difference between Adult and Child Race IAT scores (difference = 0.06, P = .15). Implicit bias was not associated with resident demographic characteristics, including specialty.

CONCLUSIONS

This is the first study demonstrating that resident physicians have implicit racial bias against black children, similar to levels of bias against black adults. Bias in our study did not vary by resident demographic characteristics, including specialty, suggesting that pediatric residents are as susceptible as other physicians to implicit bias. Future studies are needed to explore how physicians' implicit attitudes toward parents and children may impact inequities in pediatric health care.

Do attitudes and behavior of health care professionals exacerbate health care disparities among immigrant and ethnic minority groups? An integrative literature review

OBJECTIVES

Recent investigations of ethnicity related disparities in health care have focused on the contribution of providers' implicit biases. A significant effect on health care outcomes is suggested, but the results are mixed. The purpose of this integrative literature review is to provide an overview and synthesize the current empirical research on the potential influence of health care professionals' attitudes and behaviors towards ethnic minority patients on health care disparities.

DESIGN

Integrative literature review.

DATA SOURCES

Four internet-based literature indexes - MedLine, PsychInfo, Sociological Abstracts and Web of Science - were searched for articles published between 1982 and 2012 discussing health care professionals' attitudes or behaviors towards ethnic minority patients.

REVIEW METHODS

Thematic analysis was used to synthesize the relevant findings.

RESULTS

We found 47 studies from 12 countries. Six potential barriers to health care for ethnic minorities were identified that may be related to health care professionals' attitudes or behaviors: Biases, stereotypes and prejudices; Language and communication barriers; Cultural misunderstandings; Gate-keeping; Statistical discrimination; Specific challenges of delivering care to undocumented migrants.

CONCLUSIONS

Data on health care professionals' attitudes or behaviors are both limited and inconsistent. We thus provide reflections on methods, conceptualization, interpretation and the importance of the geographical or socio-political settings of potential studies. More empirical data is needed, especially on health care professionals' attitudes or behaviors towards (irregular) migrant patients.

Study of Individualization and Bias in Nursing Home Fall Prevention Practices

OBJECTIVES

Little is known about how nursing home staff use resident characteristics to individualize care delivery or whether care is affected by implicit bias.

DESIGN

Randomized factorial clinical vignette survey.

SETTING

Sixteen nursing homes in North Carolina.

PARTICIPANTS

Nursing, rehabilitation, and social services staff (n = 433).

MEASUREMENTS

Vignettes describing hypothetical residents were generated from a matrix of clinical and demographic characteristics. Resident age, race and gender were suggested by a photo. Participants completed up to four randomly assigned vignettes (n = 1615), rating the likelihood that 12 fall prevention activities would be used for the resident. Fixed and random effects mixed model analysis examined the impact of vignette resident characteristics and staff characteristics on four intervention categories.

RESULTS

Staff reported a higher likelihood of fall prevention activities in all four categories for residents with a prior fall (0.2-0.5 points higher, 10 point scale, P < 0.05), but other risk factors did not affect scores. There was little evidence of individualization; only dementia increased the reported likelihood of environmental modification (0.3, P < 0.001, 95% CI 0.2-0.5). Individualization did not vary with staff licensure category or clinical experience. Registered nurses consistently reported higher likelihoods of all fall prevention activities than did licensed practical nurses, unlicensed staff and other professional staff (1.0-2.7 points, P < 0.001 to 0.005). There was a small degree of implicit racial bias; staff indicated that environmental modification would be less likely to occur in otherwise identical vignettes including a photo of a black rather than a white resident (-0.2 points, 95% CI -0.3 to -0.1).

CONCLUSION

Nursing home staff report a standardized approach to fall prevention without individualization. We found a small impact from implicit racial bias that should be further explored.

Through the Veil of Language: Exploring the Hidden Curriculum for the Care of Patients With Limited English Proficiency

PURPOSE

Patients with limited English proficiency (LEP) experience lower-quality health care and are at higher risk of experiencing adverse events than fluent English speakers. Despite some formal training for health professions students on caring for patients with LEP, the hidden curriculum may have a greater influence on learning. The authors designed this study to characterize the hidden curriculum that medical and nursing students experience regarding the care of patients with LEP.

METHOD

In 2014, the authors invited students from one medical school and one nursing school, who had completed an interprofessional pilot curriculum on caring for patients with LEP 6 to 10 months earlier, to participate in semistructured interviews about their clinical training experiences with LEP patients. The authors independently coded the interview transcripts, compared them for agreement, and performed content analysis to identify major themes.

RESULTS

Thirteen students (7 medical and 6 nursing students) participated. Four major themes emerged: role modeling, systems factors, learning environment, and organizational culture. All 13 students described negative role modeling experiences, and most described role modeling that the authors coded as "indifferent." Students felt that the current system and learning environment did not support or emphasize high-quality care for patients with LEP.

CONCLUSIONS

The hidden curriculum that health professional students experience regarding the care of patients with LEP is influenced by systems limitations and a learning environment and organizational culture that value efficiency over effective communication. Role modeling seems strongly linked to these factors as supervisors struggle with these same challenges.

When Race Matters on the Wards: Talking About Racial Health Disparities and Racism in the Clinical Setting

INTRODUCTION

There is a growing body of literature illustrating the negative impact of racial bias on clinical care. Despite the growing evidence, medical schools have been slow to make necessary curricular changes. Most attempts to educate on racial health disparities focus on transferring knowledge and do not foster the development of skills to understand one's own bias or address bias and racism in the clinical setting. To address this, we developed a small-group, case-based curriculum for rising third-year medical students.

METHODS

This session was designed to be delivered in concurrently run, 1-hour small-group sessions, with each small group ideally comprising no more than 10 students and one facilitator. The curriculum was integrated into an existing 3-week clerkship preparation course for 122 students during the 2015-2016 academic year. The session materials include a facilitator's guide and three cases for discussion.

RESULTS

The session was evaluated using a 6-point Likert scale (1 = poor, 6 = exceptional). Students rated this session overall a 4.28 out of 6 (N = 79). Qualitative feedback varied, with the most common theme focusing on the need for more time to discuss this topic.

DISCUSSION

Though one session before starting clinical clerkships is not enough to maintain the practice of sustained critical thinking regarding bias and racism in clinical medicine, this session is a starting point for curriculum developers looking to use an evidence-based approach to racial bias in clinical care.

Pipeline program recruits and retains women and underrepresented minorities in procedure based specialties: A brief report

As the US population continues to grow in racial and ethnic diversity, we also continue to see healthcare disparities across racial lines. Considerable attention has been given to creating a physician workforce that better reflects the population served by healthcare professionals. To address the low numbers of women and underrepresented minorities in procedural based specialties, Nth Dimensions has sought to address and eliminate healthcare disparities through strategic pipeline initiatives. This is a retrospective observational cohort study of 118 medical students from 29 accredited US medical schools, who were awarded a position in the Nth Dimensions Summer Internship program between 2005 and 2012. Overall, 84 NDSI scholars applied and 81 matched into procedure-based specialties; therefore the overall retention rate was 75% and the overall match rate across the eight cohorts was 72.3%. Through intervention-based change, the authors hypothesize that greater numbers in the residency training cohorts can lead to a greater number of physicians with diverse backgrounds and perspectives. Ultimately, this will enhance quality of care for all patients and improve decision making process that influence healthcare systems.

SUMMARY

Strategic pipeline programs increase successful recruit women and underrepresented minorities to apply and matriculate into procedure based residency programs. This is a retrospective observational cohort study of 118 medical students who completed the Nth Dimensions Summer Internship program between 2005 and 2012. Overall, 84 NDSI scholars applied and 81 matched into procedure-based specialties; therefore the overall retention rate was 75% and the overall match rate across the eight cohorts was 72.3%.

Clinical Toxicology and Its Relevance to Asthma and Atopy

Although both the prevalence of asthma and the prescription drug use, notably the opiate analgesic class, epidemics are increasing, there is a complex interplay between both disorders, with both protective and exacerbating factors involved in the effect of opiates on asthma pathogenesis and clinical severity. This review examines the airway effects, both immunologic and neurologic, of opiates, which may interact and result in protection or exacerbation of asthma.

Barriers to Clinical Trial Enrollment in Racial and Ethnic Minority Patients With Cancer

BACKGROUND

Clinical trials that study cancer are essential for testing the safety and effectiveness of promising treatments, but most people with cancer never enroll in a clinical trial - a challenge exemplified in racial and ethnic minorities. Underenrollment of racial and ethnic minorities reduces the generalizability of research findings and represents a disparity in access to high-quality health care.

METHODS

Using a multilevel model as a framework, potential barriers to trial enrollment of racial and ethnic minorities were identified at system, individual, and interpersonal levels. Exactly how each level directly or indirectly contributes to doctor-patient communication was also reviewed. Selected examples of implemented interventions are included to help address these barriers. We then propose our own evidence-based intervention addressing barriers at the individual and interpersonal levels.

RESULTS

Barriers to enrolling a diverse population of patients in clinical trials are complex and multilevel. Interventions focused at each level have been relatively successful, but multilevel interventions have the greatest potential for success.

CONCLUSION

To increase the enrollment of racial and ethnic minorities in clinical trials, future interventions should address barriers at multiple levels.

Variation in advanced imaging for pediatric patients with abdominal pain discharged from the ED

BACKGROUND

Pediatric abdominal pain visits to emergency departments (ED) are common. The objectives of this study are to assess variation in imaging (ultrasound ±computed tomography [CT]) and factors associated with isolated CT use.

METHODS

This was a retrospective cohort study of ED visits for pediatric abdominal pain resulting in discharge from 16 regional EDs from 2007 to 2013. Primary outcome was ultrasound or CT imaging. Secondary outcome was isolated CT use. We used multivariable logistic regression to evaluate patient- and hospital-level covariates associated with imaging.

RESULTS

Of the 21 152 visits, imaging was performed in 29.7%, and isolated CT in 13.4% of visits. In multivariable analysis, black patients (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.4-0.5) and Medicaid (OR, 0.6; 95% CI, 0.5-0.7) had lower odds of advanced imaging compared with white patients and private insurance, respectively. General EDs were less likely to perform imaging (OR, 0.6; 95% CI, 0.5-0.7) compared with the pediatric ED; however, for visits with imaging, 3.5% of visits to the pediatric ED compared with 76% of those to general EDs included an isolated CT (P<.001). Low pediatric volume (OR, 1.8; 95% CI, 1.5-2.2) and rural (OR,1.8; 95% CI, 1.3-2.5) EDs had higher odds of isolated CT use, compared with higher pediatric volumes and nonrural EDs, respectively.

CONCLUSION

There are racial and insurance disparities in imaging for pediatric abdominal pain. General EDs are less likely than pediatric EDs to use imaging, but more likely to use isolated CT. Strategies are needed to minimize disparities and improve the use of "ultrasound first."

Reducing Implicit Gender Leadership Bias in Academic Medicine With an Educational Intervention

PURPOSE

One challenge academic health centers face is to advance female faculty to leadership positions and retain them there in numbers equal to men, especially given the equal representation of women and men among graduates of medicine and biological sciences over the last 10 years. The purpose of this study is to investigate the explicit and implicit biases favoring men as leaders, among both men and women faculty, and to assess whether these attitudes change following an educational intervention.

METHOD

The authors used a standardized, 20-minute educational intervention to educate faculty about implicit biases and strategies for overcoming them. Next, they assessed the effect of this intervention. From March 2012 through April 2013, 281 faculty members participated in the intervention across 13 of 18 clinical departments.

RESULTS

The study assessed faculty members' perceptions of bias as well as their explicit and implicit attitudes toward gender and leadership. Results indicated that the intervention significantly changed all faculty members' perceptions of bias (P < .05 across all eight measures). Although, as expected, explicit biases did not change following the intervention, the intervention did have a small but significant positive effect on the implicit biases surrounding women and leadership of all participants regardless of age or gender (P = .008).

CONCLUSIONS

These results suggest that providing education on bias and strategies for reducing it can serve as an important step toward reducing gender bias in academic medicine and, ultimately, promoting institutional change, specifically the promoting of women to higher ranks.

Examining the Presence, Consequences, and Reduction of Implicit Bias in Health Care: A Narrative Review

Recent evidence suggests that one possible cause of disparities in health outcomes for stigmatized groups is the implicit biases held by health care providers. In response, several health care organizations have called for, and developed, new training in implicit bias for their providers. This review examines current evidence on the role that provider implicit bias may play in health disparities, and whether training in implicit bias can effectively reduce the biases that providers exhibit. Directions for future research on the presence and consequences of provider implicit bias, and best practices for training to reduce such bias, will be discussed.

Marginalization: A Revisitation With Integration of Scholarship on Globalization, Intersectionality, Privilege, Microaggressions, and Implicit Biases

In 1994, the concept of marginalization was explored in an article in Advances in Nursing Science. This is a revisitation of the concept incorporating new scholarship. This update is founded on feminism, postcolonialism, critical race theory, and discourse deconstruction, all viewpoints that have been explicated in nursing. The purpose of this analysis is to look at new scholarship and concepts useful to applying marginalization in nursing knowledge development from the standpoint of Bourdieu's macro, meso, and micro levels. New scholarship includes globalization, intersectionality, privilege, microaggressions, and implicit bias. Implications for decreasing health disparities through this new scholarship are discussed.

The influence of patients' immigration background and residence permit status on treatment decisions in health care. Results of a factorial survey among general practitioners in Switzerland

This study examines the influence of patients' immigration background and residence permit status on physicians' willingness to treat patients in due time. A factorial survey was conducted among 352 general practitioners with a background in internal medicine in a German-speaking region in Switzerland. Participants expressed their self-rating (SR) as well as the expected colleague-rating (CR) to provide immediate treatment to 12 fictive vignette patients. The effects of the vignette variables were analysed using random-effects models. The results show that SR as well as CR was not only influenced by the medical condition or the physicians' time pressure, but also by social factors such as the ethnicity and migration history, the residence permit status, and the economic condition of the patients. Our findings can be useful for the development of adequate, practically relevant teaching and training materials with the ultimate aim to reduce unjustified discrimination or social rationing in health care.

African Americans Have Better Outcomes for Five Common Gastrointestinal Diagnoses in Hospitals With More Racially Diverse Patients

OBJECTIVES

We sought to characterize the relationship between hospital inpatient racial diversity and outcomes for African-American patients including rates of major complications or mortality during hospitalization for five common gastrointestinal diagnoses.

METHODS

Using the 2012 National Inpatient Sample database, hospital inpatient racial diversity was defined as the percentage of African-American patients discharged from each hospital. Logistic regression was used to predict major complication rates or death, long length of stay, and high total charges. Control variables included age, gender, payer type, patient location, area-associated income quartile, hospital characteristics including size, urban vs. rural, teaching vs. nonteaching, region, and the interaction of the percentage of African Americans with patient race.

RESULTS

There were 848,395 discharges across 3,392 hospitals. The patient population was on average 27% minority (s.d.±21%) with African Americans accounting for 14% of all patients. Overall, African-American patients had higher rates of major complications or death relative to white patients (adjusted odds ratio (aOR) 1.19; 95% confidence interval (CI) 1.16-1.23). However, when treated in hospitals with higher patient racial diversity, African-American patients experienced significantly lower rates of major complications or mortality (aOR 0.80; 95% CI 0.74-0.86).

CONCLUSIONS

African Americans have better outcomes for five common gastrointestinal diagnoses when treated in hospitals with higher inpatient racial diversity. This has major ramifications on total hospital charges.

Lost in dissociation: The main paradigms in unconscious cognition

Contemporary studies in unconscious cognition are essentially founded on dissociation, i.e., on how it dissociates with respect to conscious mental processes and representations. This is claimed to be in so many and diverse ways that one is often lost in dissociation. In order to reduce this state of confusion we here carry out two major tasks: based on the central distinction between cognitive processes and representations, we identify and isolate the main dissociation paradigms; we then critically analyze their key tenets and reported findings.

A closer look at the discrimination outcomes in the IAT literature

To what extent the IAT (Implicit Association Test, Greenwald et al., 1998) predicts racial and ethnic discrimination is a heavily debated issue. The latest meta-analysis by Oswald et al. (2013) suggests a very weak association. In the present meta-analysis, we switched the focus from the predictor to the criterion, by taking a closer look at the discrimination outcomes. We discovered that many of these outcomes were not actually operationalizations of discrimination, but rather of other related, but distinct, concepts, such as brain activity and voting preferences. When we meta-analyzed the main effects of discrimination among the remaining discrimination outcomes, the overall effect was close to zero and highly inconsistent across studies. Taken together, it is doubtful whether the amalgamation of these outcomes is relevant criteria for assessing the IAT's predictive validity of discrimination. Accordingly, there is also little evidence that the IAT can meaningfully predict discrimination, and we thus strongly caution against any practical applications of the IAT that rest on this assumption. However, provided that the application is thoroughly informed by the current state of the literature, we believe the IAT can still be a useful tool for researchers, educators, managers, and students who are interested in attitudes, prejudices, stereotypes, and discrimination.

The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias

OBJECTIVES

The emergency department (ED) is characterized by stressors (e.g., fatigue, stress, time pressure, and complex decision-making) that can pose challenges to delivering high-quality, equitable care. Although it has been suggested that characteristics of the ED may exacerbate reliance on cognitive heuristics, no research has directly investigated whether stressors in the ED impact physician racial bias, a common heuristic. We seek to determine if physicians have different levels of implicit racial bias post-ED shift versus preshift and to examine associations between demographics and cognitive stressors with bias.

METHODS

This repeated-measures study of resident physicians in a pediatric ED used electronic pre- and postshift assessments of implicit racial bias, demographics, and cognitive stressors. Implicit bias was measured using the Race Implicit Association Test (IAT). Linear regression models compared differences in IAT scores pre- to postshift and determined associations between participant demographics and cognitive stressors with postshift IAT and pre- to postshift difference scores.

RESULTS

Participants (n = 91) displayed moderate prowhite/antiblack bias on preshift (mean ± SD = 0.50 ± 0.34, d = 1.48) and postshift (mean ± SD = 0.55 ± 0.39, d = 1.40) IAT scores. Overall, IAT scores did not differ preshift to postshift (mean increase = 0.05, 95% CI = -0.02 to 0.14, d = 0.13). Subanalyses revealed increased pre- to postshift bias among participants working when the ED was more overcrowded (mean increase = 0.09, 95% CI = 0.01 to 0.17, d = 0.24) and among those caring for >10 patients (mean increase = 0.17, 95% CI = 0.05 to 0.27, d = 0.47). Residents' demographics (including specialty), fatigue, busyness, stressfulness, and number of shifts were not associated with postshift IAT or difference scores. In multivariable models, ED overcrowding was associated with greater postshift bias (coefficient = 0.11 per 1 unit of NEDOCS score, SE = 0.05, 95% CI = 0.00 to 0.21).

CONCLUSIONS

While resident implicit bias remained stable overall preshift to postshift, cognitive stressors (overcrowding and patient load) were associated with increased implicit bias. Physicians in the ED should be aware of how cognitive stressors may exacerbate implicit racial bias.