Is primary care providers' trust in socially marginalized patients affected by race?

Patient and caregiver perspectives on causes and prevention of ambulatory adverse events: multilingual qualitative study

CONTEXT

Ambulatory adverse events (AEs) affect up to 25% of the global population and cause over 7 million preventable hospital admissions around the world. Though patients and caregivers are key actors in promoting and monitoring their own ambulatory safety, healthcare teams do not traditionally partner with patients in safety efforts. We sought to identify what patients and caregivers contribute when engaged in ambulatory AE review, focusing on under-resourced care settings.

METHODS

We recruited adult patients, caregivers and patient advisors who spoke English, Spanish and/or Cantonese, from primary care clinics affiliated with a public health network in the USA. All had experience taking or managing a high-risk medication (blood thinners, insulin or opioid). We presented two exemplar ambulatory AEs: one involving a warfarin drug-drug interaction, and one involving delayed diagnosis of colon cancer. We conducted semistructured focus groups and interviews to elicit participants' perceptions of causal factors and potential preventative measures for similar AEs. The study team conducted a mixed inductive-deductive qualitative analysis to derive major themes.

FINDINGS

The sample included 6 English-speaking patients (2 in the focus group, 4 individual interviews), 6 Spanish-speaking patients (individual interviews), 4 Cantonese-speaking patients (2 in the focus group, 2 interviews), and 6 English-speaking patient advisors (focus group). Themes included: (1) Patients and teams have specific safety responsibilities; (2) Proactive communication drives safe ambulatory care; (3) Barriers related to limited resources contribute to ambulatory AEs. Patients and caregivers offered ideas for operational changes that could drive new safety projects.

CONCLUSIONS

An ethnically and linguistically diverse group of primary care patients and caregivers defined their agency in ensuring ambulatory safety and offered pragmatic ideas to prevent AEs they did not directly experience. Patients and caregivers in a safety net health system can feasibly participate in AE review to ensure that safety initiatives include their valuable perspectives.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Examining Racial/Ethnic Disparities in Tobacco Dependence Treatment Among Medicaid Beneficiaries Using Fifty State Medicaid Claims, 2009-2014

In the USA, low-income racial/ethnic minority groups experience higher smoking rates and greater smoking-related disease burden than their White counterparts. Despite the adverse effects, racial/ethnic minorities are less likely to access tobacco dependence treatment (TDT). Medicaid is one of the largest payers of TDT in the USA and covers predominantly low-income populations. The extent of TDT use among beneficiaries from distinct racial/ethnic groups is unknown. The objective is to estimate racial/ethnic differences in TDT use among Medicaid fee-for-service beneficiaries. Using a retrospective study design and 50 state (including the District of Columbia) Medicaid claims (2009-2014), we employed multivariable logistic regression models and predictive margin methods to estimate TDT use rates among adults (18-64) enrolled (≥ 11 months) in Medicaid fee-for-service programs (January 2009-December 2014) by race/ethnicity. The population included White (n = 6,536,004), Black (n = 3,352,983), Latinx (n = 2,264,647), Asian (n = 451,448), and Native American/Alaskan Native (n = 206,472) beneficiaries. Dichotomous outcomes reflected service use in the past year. Any TDT use was operationalized as any smoking cessation medication fill, any smoking cessation counseling visit, or any smoking cessation outpatient visit. In secondary analyses, we disaggregated TDT use into three separate outcomes. Results suggested that Black (10.6%; 95% CI = 9.9-11.4%), Latinx (9.5%; 95% CI = 8.9-10.2%), Asian (3.7%; 95% CI = 3.4-4.1%), and Native American/Alaskan Native (13.7%; 95% CI = 12.7-14.7%) beneficiaries had lower TDT use rates compared to White beneficiaries (20.6%). Similar racial/ethnic treatment disparities were identified across all outcomes. By identifying significant racial/ethnic disparities in TDT use between 2009 and 2014, this study provides a benchmark against which to measure recent interventions in state Medicaid programs improving equity in smoking cessation interventions.

Examining Racial/Ethnic Differences in Patterns of Opioid Prescribing: Results from an Urban Safety-Net Healthcare System

Prescription opioids still account for a large proportion of overdose deaths and contribute to opioid use dependence (OUD). Studies earlier in the epidemic suggest clinicians were less likely to prescribe opioids to racial/ethnic minorities. As OUD-related deaths have increased disproportionately amongst minority populations, it is essential to understand racial/ethnic differences in opioid prescribing patterns to inform culturally sensitive mitigation efforts. The purpose of this study is to estimate racial/ethnic differences in opioid medication use among patients prescribed opioids. Using electronic health records and a retrospective cohort study design, we estimated multivariable hazard models and generalized linear models, assessing racial/ethnic differences in OUD diagnosis, number of opioid prescriptions, receiving only one opioid prescription, and receiving ≥18 opioid prescriptions. Study population (N=22,201) consisted of adult patients (≥18years), with ≥3 primary care visits (ensuring healthcare system linkage), ≥1 opioid prescription, who did not have an OUD diagnoses prior to the first opioid prescription during the 32-month study period. Relative to racial/ethnic minority patients, White patients, in both unadjusted and adjusted analyses, had a greater number of opioid prescriptions filled, a higher proportion received ≥18 opioid prescriptions, and a greater hazard of having an OUD diagnosis subsequent to receiving an opioid prescription (all groups p<0.001). Although opioid prescribing rates have declined nationally, our findings suggest White patients still experience a high volume of opioid prescriptions and greater risk of OUD diagnosis. Racial/ethnic minorities are less likely to receive follow-up pain medications, which may signal low care quality. Identifying provider bias in pain management of racial/ethnic minorities could inform interventions seeking balance between adequate pain treatment and risk of opioid misuse/abuse.

Typologies of Family Dependency Treatment Court Participants: Parental Characteristics and Differential Child Placement Outcomes

Background: Family Dependency Treatment Court (FDTC) is a problem-solving court for parents who have child welfare involvement and designed to address parental substance misuse by providing treatment and wrap-around services, with the goal of reunifying parents with their children. Objectives: This study aimed to identify different classes of FDTC parents and compare how child placement outcomes differ by class. Parental characteristics and permanent placement outcomes for 354 parents participating in a Central Florida FDTC were assessed using administrative data. An exploratory latent class analysis was conducted to classify parents. Results: Results revealed three distinct classes of FDTC participants: 1) co-occurring issues, 2) racial/ethnic minority participants, and 3) prescription opioid, meth, and heroin users. Regression analyses showed that parents with co-occurring issues were over two times more likely to achieve permanency (OR = 2.05, p < .05), and were two times less likely to terminate their parental rights (TPR) compared to the other two classes. Conclusions: Implications for tailoring FDTC procedures to parents' individual needs, combating racial/ethnic disparities in access to services and placement outcomes, and improved child welfare and placement outcomes are discussed.

Advancing equity in challenging times: A qualitative study of telehealth expansion and changing patient-provider relationships in primary care settings during the COVID-19 pandemic

Objective

The patient-provider relationship is critical for achieving high-quality care and better health outcomes. During the COVID-19 pandemic, primary care practices rapidly transitioned to telehealth. While telehealth provided critical access to services for many, not all patients could optimally utilize it, raising concerns about its potential to exacerbate inequities in patient-provider relationships. We investigated technical and workforce-related barriers to accessing telehealth and the impacts on patient-provider relationships for vulnerable populations.

Methods

Qualitative, semi-structured interviews from May 2021 to August 2021 with 31 individuals (medical directors, physicians, and medical assistants) working at 20 primary care practices in Massachusetts, North Carolina, and Texas. Thematic analysis to better understand how barriers to using telehealth complicated patient-provider relationships.

Results

Interviewees shared challenges for providers and patients that had a negative effect on patient-provider relationships, particularly for vulnerable patients, including older adults, lower socio-economic status patients, and those with limited English proficiency. Providers faced logistical challenges and disruptions in team-based care, reducing care coordination. Patients experienced technological challenges that made accessing and engaging in telehealth difficult. Interviewees shared challenges for patient-provider relationships as commonly used telephone-only telehealth reduced channels for non-verbal communication.

Conclusion

This study indicates that barriers to virtual interaction with patients compared to in-person care likely led to weaker personal relationships that may have longer-term effects on engagement with and trust in the healthcare system, particularly among vulnerable patient groups. Additional support and resources should be available to primary care providers to optimize telehealth utilization.

Individual, interpersonal, and organisational factors associated with discrimination in medical decisions affecting people with a migration background with mental health problems: the case of general practice

OBJECTIVES

Although people with a migration background (MB) have more unmet mental health needs than the general population, patients with a MB are still underrepresented in mental health care services. Provider bias towards these patients has been evidenced repeatedly but its driving factors remain elusive. We assessed the moderating effect of the individual (e.g. age and ethnicity), interpersonal (e.g. healthcare provider trust), and organisational (e.g. perceived workload) factors on general practitioners (GPs) differential decision-making regarding diagnosis, treatment, and referral for a depressed patient with or without a MB.

DESIGN

An experimental study was carried out in which GPs were shown one of two video vignettes featuring adult male depressed patients, one with a MB and the other without. Belgian GPs (n = 797, response rate was 13%) had to decide on their diagnosis, treatment, and referral. Analysis of variance and logistic regression were used to analyse the effect of a MB, adding interaction terms for the explanatory variables.

RESULTS

Overall, we found that there were ethnic differences in GPs' decisions regarding diagnosis and treatment recommendations. GPs perceived the symptoms of the patient with a MB as less severe (F = 7.68, p < 0.01) and demonstrated a reduced likelihood to prescribe a combination of medical and non-medical treatments (F = 11.55, p < 0.001). Those differences increased in accordance with the GP's age and perceived workload; at an interpersonal level, we found that differences increased when the GP thought the patient was exaggerating his distress.

CONCLUSION

This paper showed that lower levels of trust among GPs' towards their migrant patients and high GP workloads contribute to an increased ethnic bias in medical decision-making. This may perpetuate ethnic inequalities in mental health care. Future researchers should develop an intervention to decrease the ethnic inequities in mental health care by addressing GPs' trust in their migrant and ethnic minority patients.

Cultural Framing and the Impact On Acute Pain and Pain Services

PURPOSE OF REVIEW

Optimal treatment requires a thorough understanding of all factors contributing to pain in the individual patient. In this review, we investigate the influence of cultural frameworks on pain experience and management.

RECENT FINDINGS

The loosely defined concept of culture in pain management integrates a predisposing set of diverse biological, psychological and social characteristics shared within a group. Cultural and ethnic background strongly influence the perception, manifestation, and management of pain. In addition, cultural, racial and ethnic differences continue to play a major role in the disparate treatment of acute pain. A holistic and culturally sensitive approach is likely to improve pain management outcomes, will better cover the needs of diverse patient populations and help reduce stigma and health disparities. Mainstays include awareness, self-awareness, appropriate communication, and training.

Patients' Positions on the Degree of Trust to be Placed in Physicians

Patient-physician relationship is ideally based on mutual trust. Trust usually takes times to build but can quite instantaneously be destroyed as a result of a single action or a single misperception. This study examined the way patients conceptualize the relationship between trust in a physician and perceived competency, honesty and openness, and personal involvement in care. One hundred sixty-seven patients aged 18-85 years were presented with a set of 27 three-item realistic vignettes that described situations in which participants could find themselves if hospitalized because of illness or accident. These scenarios resulted from the complete crossing of the three factors mentioned above. Participants were asked to assess the level of trust they would feel in each case. Through cluster analysis, three positions were found. For a minority of participants, trust was either unconditionally high (4%) or always quite low (8%). For a majority (75%), however, trust depended interactively on competency and honesty, on the one hand, and involvement, on the other hand; that is, the impact of competency and honesty on trust always depended on the level of involvement in care. In particular, when involvement had a low level, trust was always quite low, irrespective of the levels of both other factors. These findings are fully consistent with the view that, for a majority of patients, trust is inherently brittle: A breach in any one of participants' expectations regarding physicians' professionalism is enough to result in a more than proportional reduction in trust level.

Are Medical Students More Prejudiced? Comparison of University Students' Attitudes Towards Sexual Minorities by Faculties and Cultural background: A Study From Hungary

Sexual and gender minorities often experience discrimination or stigmatization during health encounters. When patients feel stigmatized, they are more likely to delay seeking help and it affects patient cooperation and compliance, thus undermining therapeutic efficacy itself. We examined knowledge and attitude toward LGBT+ people among Hungarian (n = 743) and foreign (n = 130) medical students of the four Hungarian medical universities and 188 students from other faculties. Homonegativity and inadequate knowledge about sexual minority individuals are correlated with male gender, conservative political views, religiosity, religious behavior, and the absence of LGBT+ acquaintance. Medical students show more negative attitudes than students from other disciplines, although foreign medical students were more accepting than Hungarian program students. Further investigation of sexual minority-related content of the Hungarian medical education and revising the written and hidden curriculum would be desired, as well as collecting data from postgraduate students, physicians, and wide range of university faculties.

County-level social vulnerability and nonfatal drug overdose emergency department visits and hospitalizations, January 2018-December 2020

BACKGROUND

Nonfatal drug overdoses (NFODs) are often attributed to individual behaviors and risk factors; however, identifying community-level social determinants of health (SDOH) associated with increased NFOD rates may allow public health and clinical providers to develop more targeted interventions to address substance use and overdose health disparities. CDC's Social Vulnerability Index (SVI), which aggregates social vulnerability data from the American Community Survey to produce ranked county-level vulnerability scores, can help identify community factors associated with NFOD rates. This study aims to describe associations between county-level social vulnerability, urbanicity, and NFOD rates.

METHODS

We analyzed county-level 2018-2020 emergency department (ED) and hospitalization discharge data submitted to CDC's Drug Overdose Surveillance and Epidemiology system. Counties were ranked in vulnerability quartiles based on SVI data. We used crude and adjusted negative binomial regression models, by drug category, to calculate rate ratios and 95% confidence intervals comparing NFOD rates by vulnerability.

RESULTS

Generally, as social vulnerability scores increased, ED and hospitalization NFOD rates increased; however, the magnitude of the association varied across drugs, visit type, and urbanicity. SVI-related theme and individual variable analyses highlighted specific community characteristics associated with NFOD rates.

CONCLUSIONS

The SVI can help identify associations between social vulnerabilities and NFOD rates. Development of an overdose-specific validated index could improve translation of findings to public health action. The development and implementation of overdose prevention strategies should consider a socioecological perspective and address health inequities and structural barriers associated with increased risk of NFODs at all levels of the social ecology.

Racial disparities in the pharmacological treatment of insomnia: A time-to-event analysis using real-world data

OBJECTIVE

Examine the association between race and time to pharmacologic treatment of insomnia in a large multi-institutional cohort.

METHODS

Retrospective analysis of electronic medical records from a regional health information exchange. Eligible patients included adults with at least one healthcare visit per year from 2010 to 2019, a new insomnia diagnosis code during the study period, and no prior insomnia diagnosis codes or medications. A Cox frailty model was used to examine the association between race and time to an insomnia medication after diagnosis.

RESULTS

In total, 9557 patients were analyzed, 7773 (81.3%) of whom where White, 1294 (13.5%) Black, 238 (2.5%) Other, and 252 (2.6%) unknown race. About 6.2% of Black and 8% of Other race patients received an order for a Food and Drug Administration-approved insomnia medication after diagnosis compared with 13.5% of White patients. Black patients were significantly less likely to have an order for a Food and Drug Administration-approved insomnia medication at all time points (adjusted hazard ratio [aHR] range: 0.37-0.73), and patients reporting Other race were less likely to have received an order at 2 (aHR 0.51, 95% confidence interval [CI] 0.28-0.94), 3 (aHR 0.33, 95% CI 0.13-0.79), and 4 years (aHR 0.21, 95% CI 0.06-0.71) of follow-up. Similar results were observed in a sensitivity analysis including off-label medications.

CONCLUSIONS

Patients belonging to racial minority groups are less likely to be prescribed an insomnia medication than White patients after accounting for sociodemographic and clinical factors. Further research is needed to determine the extent to which patient preferences and physician perceptions affect these prescribing patterns and investigate potential disparities in nonpharmacologic treatment.

Racial and Ethnic Disparities among Participants in Hepatocellular Carcinoma Clinical Studies Evaluating Transarterial Therapies

PURPOSE

To evaluate the racial and ethnic representation of transarterial therapy for hepatocellular carcinoma (HCC) clinical trials in the United States.

MATERIALS AND METHODS

The ClinicalTrials.gov database was examined to identify all completed studies with transarterial therapies for the management of HCC in the United States and extract information about the observed number of participants for each racial and ethnic group (based on the Office of Management and Budget definitions). The expected number of participants was calculated by multiplying the total number of participants in a trial with the U.S.-population HCC-based proportion for each group. The effects of the study phase, funding source, number of centers involved in the study, and the location of the participating center on racial and ethnic distribution were explored.

RESULTS

Seventy-nine relevant studies were identified, of which 27 (34.2%) and 18 (22.8%) reported ethnic and race characteristics, respectively. Most study participants were White (81%, 1,591/1,964) by ethnicity and not Hispanic or Latino (93%, 937/1,008) by race. In terms of the observed-to-expected ratios by race and ethnicity in all trials, White and not Hispanic or Latino participants were overrepresented with a ratio of 1.22 (1.10-1.37) and 1.33 (1.26-1.41), respectively, and all other racial and ethnic groups were underrepresented. The enrollment of African Americans and Asian Americans varied by the study phase, and a higher enrollment of African Americans was noted in the National Institutes of Health-funded and multicenter studies (P < .05).

CONCLUSIONS

This cross-sectional study demonstrates that in HCC transarterial therapy clinical trials, racial and ethnic minorities were underrepresented and the majority of the studies identified failed to report this demographic information.

Explicating the Cognitive Process of a Physician's Trust in Patients: A Moderated Mediation Model

Trust is considered a critical factor in the physician-patient relationship. However, little is known about the development and impact of physicians trusting their patients. A model that is premised on the integrated model of organizational trust was proposed in this article to reveal the cognitive processes involved in physicians' trust, with perceived integrity and the ability of the patient as antecedents and the physicians' communication efficacy as the outcome. A cross-sectional survey of 348 physicians in Zhejiang province, China, revealed that a physician's trust in a patient mediated the relationship between the physicians' perception of the integrity and ability of the patient, and the physician's communication efficacy. The physicians' educational backgrounds and work experience were also found to moderate an indirect effect: a lower level of education and longer work experience intensified the impact of the perceived integrity and ability of the patient on the physician's trust, while shorter work experience made the association between the physician's trust and communication efficacy more salient. This paper provided implications for both physician and patient sides.

Trajectories and correlates of opioid prescription receipt among patients experiencing interpersonal violence

Interpersonal violence increases vulnerability to the deleterious effects of opioid use. Increased opioid prescription receipt is a major contributor to the opioid crisis; however, our understanding of prescription patterns and risk factors among those with a history of interpersonal violence remains elusive. This study sought to identify 5-year longitudinal patterns of opioid prescription receipt among patients experiencing interpersonal violence within a large healthcare system and sociodemographic and clinical characteristics associated with prescription patterns. This secondary analysis examined electronic health record data from January 2004–August 2019 for a cohort of patients (N = 1,587) referred for interpersonal violence services. Latent class growth analysis was used to estimate trajectories of opioid prescription receipt over a 5-year period. Standardized differences were calculated to assess variation in sociodemographic and clinical characteristics between classes. Our cohort had a high prevalence of prescription opioid receipt (73.3%) and underlying co-morbidities, including chronic pain (54.6%), substance use disorders (39.0%), and mental health diagnoses (76.9%). Six prescription opioid receipt classes emerged, characterized by probability of any prescription opioid receipt at the start and end of the study period (high, medium, low, never) and change in probability over time (increasing, decreasing, stable). Classes with the highest probability of prescription opioids also had the highest proportions of males, chronic pain diagnoses, substance use disorders, and mental health diagnoses. Black, non-Hispanic and Hispanic patients were more likely to be in low or no prescription opioid receipt classes. These findings highlight the importance of monitoring for synergistic co-morbidities when providing pain management and offering treatment that is trauma-informed, destigmatizing, and integrated into routine care.

Association of Patient Race and Ethnicity With Differences in Opioid Prescribing by Primary Care Physicians for Older Adults With New Low Back Pain

Question

Finding

Meaning

Importance

Objective

Design, Setting, and Participants

Main Outcomes and Measures

Results

Conclusions and Relevance

Evaluation of a Chronic Pain Screening Program Implemented in Primary Care

IMPORTANCE

Although pain is among the most common symptoms reported by patients, primary care practitioners (PCPs) face substantial challenges identifying and assessing pain.

OBJECTIVE

To evaluate a 2-step process for chronic pain screening and follow-up in primary care.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study of patients with a primary care visit between July 2, 2018, and June 1, 2019, was conducted at a statewide, multisite federally qualified health center. Participants included 68 PCPs and 58 medical assistants from 13 sites who implemented the screening process in primary care, and 38 866 patients aged 18 years or older with a primary care visit during that time.

EXPOSURES

Single-question assessment of pain frequency, followed by a 3-question PEG (pain, enjoyment of life, general activity) functional assessment for patients with chronic pain.

MAIN OUTCOMES AND MEASURES

Adherence to a 2-step chronic pain screening and PEG process, proportion of patients with positive screening results, mean PEG pain severity greater than or equal to 7, and documented chronic painful condition diagnosis in patient's electronic health record between 1 year before and 90 days after screening.

RESULTS

Of 38 866 patients with a primary care visit, 31 600 patients (81.3%) underwent screening. Mean (SD) age was 46.2 (15.4) years, and most were aged 35 to 54 years (12 987 [41.1%]), female (18 436 [58.3%]), Hispanic (14 809 [46.9%]), and English-speaking (22 519 [71.3%]), and had Medicaid insurance (18 442 [58.4%]). A total of 10 262 participants (32.5%) screened positive and, of these, 9701 (94.5%) completed the PEG questionnaire. PEG responses indicated severe pain interference with activities of daily living (PEG ≥7) in 5735 (59.1%) participants. A chronic painful condition had not been diagnosed in 4257 (43.9%) patients in the year before screening. A new chronic painful condition was diagnosed at screening or within 90 days in 2250 (52.9%) patients. Care teams found the workflow acceptable, but cited lengthy administration time, challenges with comprehension of the PEG questions, and limited comprehensiveness as implementation barriers.

CONCLUSIONS AND RELEVANCE

A systematic, 2-step process for chronic pain screening and functional assessment in primary care appeared to identify patients with previously undocumented chronic pain and was feasible to implement. Patient-provided information on the frequency of pain, pain level, and pain interference can help improve the assessment and monitoring of pain in primary care.

Fundamental causes of barriers to participation in Alzheimer's clinical research among African Americans

Objectives: African Americans have a significantly higher risk than Whites for developing Alzheimer's disease (AD), but show lower participation in AD clinical trials. Studies of African Americans' involvement in clinical research have identified fear and mistrust of research as barriers to participation. Historical occurrences of unethical research practices are often cited as the source of these attitudes, but underlying factors such as African Americans' experiences of racism and discrimination remain unexplored. The goal of this study was to examine the roles of race and culture in the attitudes and beliefs of African Americans about participating in clinical research.Design: Five focus groups were conducted with 44 African American men and women (aged 50 and over) in a western U.S. state. Participants were asked scripted questions regarding their knowledge and beliefs about AD and their feelings about participating in clinical research. A taxonomy was created to organize results based on participant responses.Results: Four major thematic clusters emerged that influence African Americans beliefs about and participation in clinical research: (a) experiences of unequal treatment and racism, (b) cultural trauma due to historical events and contemporary experiences, (c) racial identity and cultural norms, and (d) the importance of cultural competency and racial congruence in recruitment and research studies.Conclusions: Understanding, acknowledging, and addressing the factors that underlie mistrust and fear of research is important to build trust and to develop culturally appropriate outreach, education, and recruitment strategies that will increase African Americans' participation in clinical research.

Race, pain, and opioids among patients with chronic pain in a safety-net health system

BACKGROUND

Recent changes in opioid prescribing practices in the US may exacerbate disparities in opioid access among Black compared to White patients.

METHODS

To evaluate racial disparities in opioid prescribing and stewardship, we used baseline data collected from 2017 to 2019 for a longitudinal cohort of patients with chronic non-cancer pain and a history of illicit substance use. Sociodemographic characteristics, pain, psychological distress, substance use, and opioid prescription practices were compared between Black and White participants. We conducted multivariable logistic regression with race as the outcome. We also compared yellow flag events (opioid-related emergency department visits, illicit substances on urine drug screens, provider-documentation of concerning behaviors) by race.

RESULTS

Over half of participants analyzed were Black (57%) and the remainder White (43%). Participants with worse average pain in the past three months (adjusted odds ratio [AOR]:1.29, 95%CI:1.08-1.55, p = 0.006) had higher odds of being Black. Past-year injection drug use (AOR:0.39, 95%CI:0.16-0.94, p = 0.04) and a higher past-year maximum opioid dose (AOR per 10 morphine milligram equivalents (MME):0.99, 95%CI:0.98-1.00, p = 0.006) were associated with lower odds of being Black. We found no differences by race in the use of opioid stewardship measures or discontinuation of opioids based on yellow flag events.

CONCLUSION

Lower past-year maximum MME dose, despite higher average pain and less injection drug use, may represent bias away from prescribing opioids for chronic pain among Black patients. This could be due to unmeasured implicit provider bias or patient-level factors (e.g., utilizing non-opioid pain coping strategies or being less likely to request additional opioids).

Racial Disparities in Sustaining Breastfeeding in a Baby-Friendly Designated Southeastern United States Hospital: An Opportunity to Investigate Systemic Racism

Background: Racial disparities in breastfeeding rates persist in the United States with Black women having the lowest rates of initiation and continuation. A literature review attributes this to many factors-historical roles, cultural norms, lack of social support, and systemic racism in the health care and lactation support system. The Baby-Friendly Hospital Initiative (BFHI) is an evidence-based program to increase breastfeeding through standardized protocols, and, in a Southeastern U.S. academic center, it was associated with increased breastfeeding, but the effect on racial disparities in breastfeeding was unknown. Methods: Through an institutional Perinatal Information Systems database, breastfeeding rates were compared before and after BFHI implementation. Breastfeeding initiation, sustained breastfeeding 24-hours before discharge, and patient demographics were assessed. Results: After BFHI implementation, mothers were overall 1.17 (95% confidence interval: 1.13-1.19) times more likely to initiate breastfeeding. For Black mothers, breastfeeding initiation increased significantly from 52% to 66%, but they were significantly less likely to sustain in-hospital breastfeeding compared to nonBlack mothers (69.4% versus 84.6%, p < 0.0001). Several demographic and medical comorbidities were significantly associated with failure to sustain breastfeeding to hospital discharge. When controlling for these factors, the racial disparity persisted. Conclusions: Since BFHI implementation, the racial gap in breastfeeding initiation decreased, but a significant disparity remained for sustained in-hospital breastfeeding. This study highlights the success of the BFHI program, but in the context of the current literature, also reveals the need for further work to ensure interventions are culturally competent and delivered equitably to support sustained breastfeeding for Black women.

Perspectives of Interactions with Healthcare Providers Among Patients Who Are Blind

Healthcare providers' (HCPs) stereotypes about the incompetence of blind and low-vision patients may lead them to patronize blind patients, over-focus on impairments, and neglect the presenting problem. The content of perceived HCP stereotypes about blind patients in the clinical setting was examined from the patient perspective with seven focus groups, including a total of 42 individual participants. Most participants reported an interaction when their HCPs treated them as if they were incompetent, and discussed how perceived evaluations of their warmth and competence impacted whether their HCPs trusted and respected them. Participants also discussed their evaluations of their HCPs' warmth and competence, and how these evaluations impacted their trust and respect for the HCP. These results provide insight into blind patients' experiences interacting with their HCPs and can inform interventions to 1) help HCPs avoid stereotypic attitudes and 2) improve HCPs' comfort and abilities when working with patient with disabilities.

Assessing Provider Bias in General Practitioners' Assessment and Referral of Depressive Patients with Different Migration Backgrounds: Methodological Insights on the Use of a Video-Vignette Study

Although the prevalence of common mental health conditions such as depression and anxiety, is higher among people with a migration background, these groups are generally underrepresented in all forms of institutionalized mental health care. At the root of this striking discrepancy might be unequal referral by health care practitioners. In this article we describe the development of a quasi-experimental video vignette methodology to assess potential forms of unequal diagnosing, treatment and referral patterns, based on clients' migration background and asylum status. The presented methodology also allows to explore whether potential differences are related to provider bias, i.e. underlying attitudes and expectations held by general practitioners. Potential assets and drawbacks of this methodology are discussed in detail.

The Relationship Between Health-Related Quality of Life and Trust in Primary Care Physicians Among Patients with Diabetes

Background

Trust is pivotal for a productive relationship between patients and healthcare providers and is positively correlated with multiple clinical and humanistic outcomes. However, the impact of trust in healthcare providers on different domains of health-related quality of life (HRQoL) among diabetic patients has not been studied in detail.

Purpose

The aim of this study was to examine the association between the physical, mental or psychological, social, and environmental domains of HRQoL with the patients’ trust in their primary care physicians while controlling for several sociodemographic and clinical factors. The study was conducted among a sample of diabetic patients.

Patients and Methods

This study had a prospective questionnaire-based, multi-center, cross-sectional design. The patients were recruited from three public hospitals in Saudi Arabia. Patients’ experiences and trust in their primary care physicians were assessed using the Health Care Relationship Trust (HCR-Trust) scale. HRQoL was assessed using the Arabic version of the World Health Organization Quality of Life-BREF (WHOQOL-BREF). Multiple linear regression was conducted to assess the relationship between HCR-Trust and the WHOQOL-BREF physical, psychological, social, and environmental domains controlling for age, Charlson Comorbidity Index (CCI) score, health literacy, sex, education, annual income, nationality, and illness duration.

Results

Three hundred and sixty-four patients participated in the study. The scores in all four domains of WHOQOL-BREF were positively associated with HCR-Trust scores of the diabetic patients. Additionally, the scores in the physical (β = −10.26; 95% CI: −13.77 to −6.74; P < 0.0001) and psychological (β = −3.91; 95% CI: −7.44 to −0.38; P < 0.0001) domains were negatively associated with female gender. Furthermore, the physical domain score was negatively associated with the duration of illness (β = −0.26; 95% CI: −0.506 to −0.02; P = 0.032). The environmental domain score was positively associated with annual income (β = 2.31; 95% CI: 1.05 to 3.56; P = 0.030). Other patient characteristics, such as age and education, were not associated with the scores of any of the WHOQOL-BREF domains.

Conclusion

Patient trust in healthcare providers is positively associated with different domains of HRQoL. Therefore, building and maintaining trust with patients is important to achieve favorable treatment outcomes.

Dynamics of Physicians' Trust in Fellow Health Care Providers and the Role of Health Information Technology

Physicians are expected and incentivized to coordinate patient care with other providers, including nonphysician clinician (NPC) members of care teams, requiring trust. Trust in the context of care teams has not been well-studied; even less is known about how health information technologies (HIT) may modify trust in these relationships. We conducted semistructured interviews with 30 physicians at a Midwestern academic center to examine how physicians determine they can trust NPCs, and how technology modifies these relationships. A majority of physicians base trust in NPCs on cognitive factors such as competence and reliability. Technology enhances trust between physicians and NPCs by supporting evidence-based decision making; it can also erode trust by limiting opportunities for developing familiarity and comfort with fellow providers. Our work has implications for enhancing HIT to promote trust between providers, and for developing more robust measures of trust that can be used in evaluating and improving teamwork within practices.

Trust in older persons: A quantitative analysis of alignment in triads of older persons, informal carers and home care nurses

Self-management by older persons could be influenced by the level of trust found in triads of informal carers, formal care providers and care recipient, the older person. Little research has been done on care providers' trust in older persons. This study aims to explore the level of trust that informal carers and home care nurses have in older persons, the extent of alignment in triads and the relationship between trust in older persons and self-management. We conducted a cross-sectional survey study in the Netherlands, sampling 133 older persons, 64 informal carers and 72 nurses, which resulted in 39 triads. Alignment level was analysed through Intraclass Correlation Coefficient 1 scores and absolute and mean difference scores. Correlation analysis and one-way analysis of variance measured the relationship between trust and self-management. The results show that triads contain both alignment and misalignment. Misalignment occurs mostly when informal carers and nurses have little trust in the older person while this person views their own behaviour towards their caregivers positively. Care providers' trust levels relate significantly to their perception of the person's ability to self-manage, but not to the person's self-rated ability. This could be explained by care providers not communicating their intrinsic trust in the older person to them. Trust building could be enhanced by organising discussions of mutual expectations of trust and both formal and informal care providers could benefit from compassionate assessment training, to learn how to openly express their trust in the older person.

Interpersonal trust in doctor-patient relation: Evidence from dyadic analysis and association with quality of dyadic communication

RATIONALE

Although they form a dyadic relationship, doctor's and patient's levels of trust in the other have usually been investigated separately. As members of dyadic relationships, they influence each other's behaviors and are interdependent because they share a past history and eventually a common future.

OBJECTIVES

The aim of this paper was to examine the composition of trust in doctor-patients relationship and estimate its association with quality of doctor's communication. One-With-Many analyses (OWM) were used to examine the composition of trust variance into "doctor and patient effects", "relationship effects", and "reciprocity effects," taking into account the interdependence of the data.

METHOD

Twelve General Practitioners (GPs; Mage = 54.16, SD = 12.28, 8 men) and 189 of their patients (Mage = 47.48, SD = 9.88, 62% women) took part in the study. GPs and their patients completed postconsultation questionnaires on trust and quality of communication.

RESULTS

The findings revealed that "doctor" and "patient" effects were significant. However, the most important part of the variance was attributable to the relationship and reciprocity effects, meaning that if a doctor reported high trust in a particular patient, then the patient reported a similarly high level of trust. Higher quality of communication was positively associated to those relationship effects of trust.

CONCLUSIONS

Our study stresses the importance to investigate trust in doctor-patients relationship as a dyadic and interdependent phenomenon applying appropriate methodological design and analysis. Convergence between doctor's and patients' perceptions of their relationship may enhance trust more than conventional intervention and may ultimately contribute to better health outcomes.

Personality and treatment-related correlates of trustworthiness: A web-survey with chronic pain narratives

OBJECTIVES

This study examined personality and treatment-related correlates of trustworthiness in chronic pain narratives.

METHODS

727 adults participated in an online survey and rated eight narratives written by patients with chronic pain. Eighty-six percent of the participants identified themselves as having experienced chronic pain (n = 626) and 14% identified themselves as people with a medical background (n = 101). The survey examined psychological characteristics, trustworthiness and expressions of pain severity, desire for medication, and frustration with pain care.

RESULTS

Pain narratives that were rated as likable, stoic, or appreciative were significantly associated with higher trustworthiness; narratives that were rated as depressed, hostile, or histrionic were significantly associated with lower trustworthiness. Similar results were found for patient peers and clinicians. Patients that expressed a high level of pain severity were rated as significantly less trustworthy (P < .001). Pain narratives that expressed frustration with pain care were also rated as significantly less trustworthy (P = .009). For pain narratives that expressed frustration with pain care, patient peers gave higher ratings of trustworthiness compared to providers (P = .008), whereas both gave similar ratings when no frustration with pain care was expressed in the narrative.

DISCUSSION

Our results show that the way in which patients communicate about their pain are significantly associated with how trustworthy they are perceived. Future research should explore how trustworthiness is related to subsequent pain management and interpersonal dynamics.

Racial and Ethnic Disparities in the Evaluation and Management of Pain in the Outpatient Setting, 2006-2015

OBJECTIVE

Much is known about racial and ethnic disparities in receipt of opioids for pain in emergency departments. Less is known about such disparities in the evaluation and management of pain in the outpatient setting.

METHODS

Using the nationally representative National Ambulatory Medical Care Survey (NAMCS), we estimated disparities in visit time with physicians and opioid receipt in the outpatient setting. We focused on patients whose reason for visiting was abdominal pain or back pain. Our sample included 4,764 white patients, 692 black patients, and 682 Hispanic patients.

RESULTS

Back pain visits of Hispanic patients lasted 1.6 fewer minutes than those of white non-Hispanic patients (P = 0.04 for the difference). Black patients were 6.0% less likely than white patients to receive opioids for abdominal pain (P = 0.04 for the difference) and 7.1% less likely than white patients to receive opioids for back pain (P = 0.046 for the difference). Hispanic patients were 6.3% less likely than white patients to receive opioids for abdominal pain (P = 0.003 for the difference) and 14.8% less likely than white patients to receive opioids for back pain (P < 0.001 for the difference). Hispanic patients were more likely than white patients to receive nonopioids instead of opioids for both abdominal pain and back pain. Differences in opioid receipt did not narrow during the examined time period.

CONCLUSIONS

Identifying causes of racial and ethnic disparities in the evaluation and treatment of pain in the outpatient setting is important to improving the health and function of patients.

Engaging African ancestry participants in SLE clinical trials

SLE is a complex autoimmune disease with genetic and clinical differences between patients that appear to reside along ancestral lines. Over the last 20 years, a preponderance of evidence has shown that SLE is more common and severe in minority populations, particularly in African ancestry (AA) women. However, in clinical trials for new therapies of SLE, AA is often under-represented. Without enrolling sufficient AA participants, it is difficult to ascertain the safety and efficacy of new potential therapies among individuals with SLE of different ancestries. Although enrolling minority populations in clinical trials has been a significant challenge for many reasons, the various stakeholders involved in clinical research could act within their own realms to develop new paradigms and policies to bolster the inclusion of AA in the development of new therapies.

"Why Even Bother; They Are Not Going to Do It?" The Structural Roots of Racism and Discrimination in Lactation Care

Through semi-structured interviews with 36 International Board Certified Lactation Consultants (IBCLCs) who assist mothers with breastfeeding, this study takes a systematic look at breastfeeding disparities. Specifically, this study documents race-based discrimination against patients in the course of lactation care and links the implicit bias literature to breastfeeding disparities. IBCLCs report instances of race-based discrimination against patients such as unequal care provided to patients of color and overt racist remarks said in front of or behind patient's backs. This study connects patient discrimination in lactation to institutional inequality and offers suggestions to address these inequities.

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).

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.

Racial-Ethnic Disparities in Opioid Prescriptions at Emergency Department Visits for Conditions Commonly Associated with Prescription Drug Abuse

Prescription drug abuse is a growing problem nationally. In an effort to curb this problem, emergency physicians might rely on subjective cues such as race-ethnicity, often unknowingly, when prescribing opioids for pain-related complaints, especially for conditions that are often associated with drug-seeking behavior. Previous studies that examined racial-ethnic disparities in opioid dispensing at emergency departments (EDs) did not differentiate between prescriptions at discharge and drug administration in the ED. We examined racial-ethnic disparities in opioid prescription at ED visits for pain-related complaints often associated with drug-seeking behavior and contrasted them with conditions objectively associated with pain. We hypothesized a priori that racial-ethnic disparities will be present among opioid prescriptions for conditions associated with non-medical use, but not for objective pain-related conditions. Using data from the National Hospital Ambulatory Medical Care Survey for 5 years (2007-2011), the odds of opioid prescription during ED visits made by non-elderly adults aged 18-65 for 'non-definitive' conditions (toothache, back pain and abdominal pain) or 'definitive' conditions (long-bone fracture and kidney stones) were modeled. Opioid prescription at discharge and opioid administration at the ED were the primary outcomes. We found significant racial-ethnic disparities, with non-Hispanic Blacks being less likely (adjusted odds ratio ranging from 0.56-0.67, p-value < 0.05) to receive opioid prescription at discharge during ED visits for back pain and abdominal pain, but not for toothache, fractures and kidney stones, compared to non-Hispanic whites after adjusting for other covariates. Differential prescription of opioids by race-ethnicity could lead to widening of existing disparities in health, and may have implications for disproportionate burden of opioid abuse among whites. The findings have important implications for medical provider education to include sensitization exercises towards their inherent biases, to enable them to consciously avoid these biases from defining their practice behavior.

Disparities in Emergency Department Pain Treatment for Toothache

Racial disparities in how pain is treated in the emergency department (ED) for toothache have not been reported. Due to increasing reliance on EDs for dental care, the authors investigated whether race/ethnicity and insurance type are associated with treatment for toothache pain. The authors conducted a nationally representative cross-sectional study of ED toothache visits by adults (19 to 64 y old), using the 2008-2010 National Hospital Ambulatory Medical Care Survey. Multinomial regression models accounted for the complex survey design. Outcomes were pain medicines received: none, nonopioid only, or opioids. After adjusting for sociodemographic factors, black patients had 1.99 greater odds (P < 0.005) than white patients of receiving only a nonopioid pain medicine for toothache. Visits made by patients on Medicare, Medicaid, uninsured, or "other" insurance status had greater odds than the privately insured of receiving only a nonopioid pain medicine rather than an opioid (odds ratios, respectively: 4.8, P < 0.001; 2.1, P ≤ 0.001; 2.3, P < 0.01; and 4.1, P < 0.001). Blacks are less likely than whites to receive opioids in the ED for a toothache, even with similar levels of pain. Nonprivately insured patients have lower odds than the privately insured to receive opioids for toothache pain. A better understanding of the etiology of these disparities could lead to directed interventions. Knowledge Transfer Statement: This study presents findings novel to the body of pain and oral health care literature. Because there is an increasing reliance on the emergency department to address dental pain, disparities in how toothache pain is treated will be of great interest to a growing number of Americans, clinicians, and policy makers.

Primary care providers' experiences with urine toxicology tests to manage prescription opioid misuse and substance use among chronic noncancer pain patients in safety net health care settings

BACKGROUND

Guideline recommendations to reduce prescription opioid misuse among patients with chronic noncancer pain include the routine use of urine toxicology tests for high-risk patients. Yet little is known about how the implementation of urine toxicology tests among patients with co-occurring chronic noncancer pain and substance use impacts primary care providers' management of misuse. Clinicians' perspectives on the benefits and challenges of implementing urine toxicology tests in the monitoring of opioid misuse and substance use in safety net health care settings are presented in this paper.

METHODS

Twenty-three primary care providers from 6 safety net health care settings whose patients had a diagnosis of co-occurring chronic noncancer pain and substance use were interviewed. Interviews were transcribed, coded, and analyzed using grounded theory methodology.

RESULTS

The benefits of implementing urine toxicology tests for primary care providers included less reliance on intuition to assess for misuse and the ability to identify unknown opioid misuse and/or substance use. The challenges of implementing urine toxicology tests included insufficient education and training about how to interpret and implement tests, and a lack of clarity on how and when to act on tests that indicated misuse and/or substance use.

CONCLUSIONS

These data suggest that primary care clinicians' lack of education and training to interpret and implement urine toxicology tests may impact their management of patient opioid misuse and/or substance use. Clinicians may benefit from additional education and training about the clinical implementation and use of urine toxicology tests. Additional research is needed on how primary care providers implementation and use of urine toxicology tests impacts chronic noncancer pain management in primary care and safety net health care settings among patients with co-occurring chronic non cancer pain and substance use.

Exploring the experience of chronic pain among female Survival Sex Workers: a qualitative study

BACKGROUND

The prevalence of self-identified chronic pain in Canadian adults is approximately one in five people. Marginalization and addictions have been shown to complicate chronic pain in vulnerable populations. This study aimed to understand the experience of chronic pain among female Survival Sex Workers in Vancouver's downtown eastside (DTES).

METHODS

This study used an exploratory qualitative analysis with in-depth, semi-structured interviews. Members of PACE Society who self-identified as a current or former Survival Sex Worker and who had a chronic pain experience known to PACE support workers were invited to participate. Interviews were conducted, audio recorded and transcribed. The investigators met to read the transcripts and discuss emerging themes. The process continued until no new themes were observed.

RESULTS

Participants ranged in age from 42 to 56 years old and all self- identified as females and Survival Sex Workers. Eleven of thirteen interviews were analyzed for themes. Drug use for pain management, both prescribed and illicit, was the most important theme. Poverty, the need to continue working and the lack of stable housing were barriers to adequately addressing the source of chronic pain. Participants felt judged for living in the downtown eastside, being a drug user and/or being Aboriginal and only two participants had been referred to a pain specialist. All participants were involved in support networks made up of other Sex Workers and all spoke of a sense of community and survival.

CONCLUSIONS

Our study emphasizes the complex nature of chronic pain and addictions among a uniquely marginalized population. The study is unique in that it contributes the perspectives of a traditionally "hard-to-reach" population and demonstrates that Sex Workers should not only participate in but should lead development and implementation of research and programs for managing chronic pain in the setting of addiction.

African migrant patients' trust in Chinese physicians: a social ecological approach to understanding patient-physician trust

Background

Patient trust in physicians is a critical determinant of health seeking behaviors, medication adherence, and health outcomes. A crisis of interpersonal trust exists in China, extending throughout multiple social spheres, including the healthcare system. At the same time, with increased migration from Africa to China in the last two decades, Chinese physicians must establish mutual trust with an increasingly diverse patient population. We undertook a qualitative study to identify factors affecting African migrants’ trust in Chinese physicians and to identify potential mechanisms for promoting trust.

Methods / Principal Findings

We conducted semi-structured, in-depth interviews with 40 African migrants in Guangzhou, China. A modified version of the social ecological model was used as a theoretical framework. At the patient-physician level, interpersonal treatment, technical competence, perceived commitment and motive, and language concordance were associated with enhanced trust. At the health system level, two primary factors influenced African migrants’ trust in their physicians: the fee-for-service payment system and lack of continuity with any one physician. Patients’ social networks and the broader socio-cultural context of interactions between African migrants and Chinese locals also influenced patients’ trust of their physicians.

Conclusions

These findings demonstrate the importance of factors beyond the immediate patient-physician interaction and suggest opportunities to promote trust through health system interventions.

Does the availability of a South Asian language in practices improve reports of doctor-patient communication from South Asian patients? Cross sectional analysis of a national patient survey in English general practices

BACKGROUND

Ethnic minorities report poorer evaluations of primary health care compared to White British patients. Emerging evidence suggests that when a doctor and patient share ethnicity and/or language this is associated with more positive reports of patient experience. Whether this is true for adults in English general practices remains to be explored.

METHODS

We analysed data from the 2010/2011 English General Practice Patient Survey, which were linked to data from the NHS Choices website to identify languages which were available at the practice. Our analysis was restricted to single-handed practices and included 190,582 patients across 1,068 practices. Including only single-handed practices enabled us to attribute, more accurately, reported patient experience to the languages that were listed as being available. We also carried out sensitivity analyses in multi-doctor practices. We created a composite score on a 0-100 scale from seven survey items assessing doctor-patient communication. Mixed-effect linear regression models were used to examine how differences in reported experience of doctor communication between patients of different self-reported ethnicities varied according to whether a South Asian language concordant with their ethnicity was available in their practice. Models were adjusted for patient characteristics and a random effect for practice.

RESULTS

Availability of a concordant language had the largest effect on communication ratings for Bangladeshis and the least for Indian respondents (p < 0.01). Bangladeshi, Pakistani and Indian respondents on average reported poorer communication than White British respondents [-2.9 (95%CI -4.2, -1.6), -1.9 (95%CI -2.6, -1.2) and -1.9 (95%CI -2.5, -1.4), respectively]. However, in practices where a concordant language was offered, the experience reported by Pakistani patients was not substantially worse than that reported by White British patients (-0.2, 95%CI -1.5,+1.0), and in the case of Bangladeshi patients was potentially much better (+4.5, 95%CI -1.0,+10.1). This contrasts with a worse experience reported among Bangladeshi (-3.3, 95%CI -4.6, -2.0) and Pakistani (-2.7, 95%CI -3.6, -1.9) respondents when a concordant language was not offered.

CONCLUSIONS

Substantial differences in reported patient experience exist between ethnic groups. Our results suggest that patient experience among Bangladeshis and Pakistanis is improved where the practice offers a language that is concordant with the patient's ethnicity.

Physicians' anxiety due to uncertainty and use of race in medical decision making

BACKGROUND

The explicit use of race in medical decision making is contested. Researchers have hypothesized that physicians use race in care when they are uncertain.

OBJECTIVES

The aim of this study was to investigate whether physician anxiety due to uncertainty (ADU) is associated with a higher propensity to use race in medical decision making.

RESEARCH DESIGN

This study included a national cross-sectional survey of general internists.

SUBJECTS

A national sample of 1738 clinically active general internists drawn from the SK&A physician database were included in the study.

MEASURES

ADU is a 5-item measure of emotional reactions to clinical uncertainty. Bonham and Sellers Racial Attributes in Clinical Evaluation (RACE) scale includes 7 items that measure self-reported use of race in medical decision making. We used bivariate regression to test for associations between physician characteristics, ADU, and RACE. Multivariate linear regression was performed to test for associations between ADU and RACE while adjusting for potential confounders.

RESULTS

The mean score on ADU was 19.9 (SD=5.6). Mean score on RACE was 13.5 (SD=5.6). After adjusting for physician demographics, physicians with higher levels of ADU scored higher on RACE (+β=0.08 in RACE, P=0.04, for each 1-point increase in ADU), as did physicians who understood "race" to mean biological or genetic ancestral, rather than sociocultural, group. Physicians who graduated from a US medical school, completed fellowship, and had more white patients scored lower on RACE.

CONCLUSIONS

This study demonstrates positive associations between physicians' ADU, meanings attributed to race, and self-reported use of race in medical decision making. Future research should examine the potential impact of these associations on patient outcomes and health care disparities.

The effect of cognitive load and patient race on physicians' decisions to prescribe opioids for chronic low back pain: a randomized trial

OBJECTIVE

To test the hypothesis that racial biases in opioid prescribing would be more likely under high levels of cognitive load, defined as the amount of mental activity imposed on working memory, which may come from environmental factors such as stressful conditions, chaotic workplace, staffing insufficiency, and competing demands, one's own psychological or physiological state, as well as from demands inherent in the task at hand.

DESIGN

Two (patient race: White vs Black) by two (cognitive load: low vs high) between-subjects factorial design.

SETTING AND PARTICIPANTS

Ninety-eight primary care physicians from the Veterans Affairs Healthcare System.

METHODS

Web-based experimental study. Physicians were randomly assigned to read vignettes about either a Black or White patient, under low vs high cognitive load, and to indicate their likelihood of prescribing opioids. High cognitive load was induced by having physicians perform a concurrent task under time pressure.

RESULTS

There was a three-way interaction between patient race, cognitive load, and physician gender on prescribing decisions (P = 0.034). Hypotheses were partially confirmed. Male physicians were less likely to prescribe opioids for Black than White patients under high cognitive load (12.5% vs 30.0%) and were more likely to prescribe opioids for Black than White patients under low cognitive load (30.8% vs 10.5%). By contrast, female physicians were more likely to prescribe opioids for Black than White patients in both conditions, with greater racial differences under high (39.1% vs 15.8%) vs low cognitive load (28.6% vs 21.7%).

CONCLUSIONS

Physician gender affected the way in which patient race and cognitive load influenced decisions to prescribe opioids for chronic pain. Future research is needed to further explore the potential effects of physician gender on racial biases in pain treatment, and the effects of physician cognitive load on pain treatment.

A systematic review of the extent and measurement of healthcare provider racism

BACKGROUND

Although considered a key driver of racial disparities in healthcare, relatively little is known about the extent of interpersonal racism perpetrated by healthcare providers, nor is there a good understanding of how best to measure such racism.

OBJECTIVES

This paper reviews worldwide evidence (from 1995 onwards) for racism among healthcare providers; as well as comparing existing measurement approaches to emerging best practice, it focuses on the assessment of interpersonal racism, rather than internalized or systemic/institutional racism.

METHODS

The following databases and electronic journal collections were searched for articles published between 1995 and 2012: Medline, CINAHL, PsycInfo, Sociological Abstracts. Included studies were published empirical studies of any design measuring and/or reporting on healthcare provider racism in the English language. Data on study design and objectives; method of measurement, constructs measured, type of tool; study population and healthcare setting; country and language of study; and study outcomes were extracted from each study.

RESULTS

The 37 studies included in this review were almost solely conducted in the U.S. and with physicians. Statistically significant evidence of racist beliefs, emotions or practices among healthcare providers in relation to minority groups was evident in 26 of these studies. Although a number of measurement approaches were utilized, a limited range of constructs was assessed.

CONCLUSION

Despite burgeoning interest in racism as a contributor to racial disparities in healthcare, we still know little about the extent of healthcare provider racism or how best to measure it. Studies using more sophisticated approaches to assess healthcare provider racism are required to inform interventions aimed at reducing racial disparities in health.