Social bias, discrimination and inequity in healthcare: mechanisms, implications and recommendations

Influence of Participant Perceptions of Adherence-Related Interactions with Study/Study Team on Drug Levels: HPTN069 Analysis of Self-Reported Adherence Experiences While on Study

Adherence to HIV pre-exposure prophylaxis (PrEP) study drug is critical for safety, tolerability, and efficacy trials, and may be affected by how adherence is communicated by the study staff to trial participants. Increasingly, clinical trials investigating PrEP are creating and implementing 'participant-centered' approaches that discuss potential non-adherence neutrally (without negative judgement) and support efforts to adhere versus insisting on perfect adherence. In the HPTN069/ACTG A5305 study, we evaluated participant experiences of potentially negative adherence-related interactions with study teams using ten items to characterize the frequency of such experiences. We related these individual items and a combined set of seven negative experience items (total negative experience score) to drug concentrations (detectable or consistent with daily-dosing). The exploratory analyses used logistic regression for each experience item on the full sample and disaggregated by sex. Several experiences were related to drug detection and to daily-dosing, although more so for participants identifying as men than women. Total negative experience scores associated with not having detection drug concentrations for the full sample, and remained significant even when controlling for sex, age, and race. Daily dosing was associated with total negative experience score for men in the sample. Additional investigations into adherence-related interactions with study teams that are most problematic or helpful in general and uniquely for men and women are warranted.

Medical Students' Self-Perceptions of Harassment During Clinical Placement

Objectives

Exploring workplace dynamics during clinical placement is crucial to determine whether medical students are encountering safe and meaningful learning experiences. The aim of this original article is to describe medical students' reported harassment experiences whilst on clinical placement.

Design

Medical students in years 4 to 6 were invited to participate in the survey. In this mixed-methods study, data collection included demographic information, responses to the Generalized Workplace Harassment Questionnaire, and qualitative commentaries.

Results

Two hundred and five students completed the questionnaire. Medical students experienced harassment in areas of verbal aggression, disrespect, isolation/exclusion, threats/bribes, and physical aggression. Concerning levels of occurrence were noted for disrespect, isolation/exclusion, and verbal aggression.

Conclusions

Many medical students in this study reported experiencing harassment during their clinical placements indicating that harassment during clinical placement continues to be of concern in medical education. The findings indicate that further initiatives need to be designed to identify and respond to these cases of workplace harassment and that power imbalance and safe reporting appear to be further issues of concern. It was evident that students need to feel safe enough to be able to report harassment experiences to allow managers and educators to address the full extent of the problem.

Interprofessional Learning in Multidisciplinary Healthcare Teams Is Associated With Reduced Patient Mortality: A Quantitative Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study is to identify quantitative evidence for the efficacy of interprofessional learning (IPL) to improve patient outcomes.

METHODS

We conducted a systematic review and meta-analysis of quantitative patient outcomes after IPL in multidisciplinary healthcare teams reported in the Medline, Scopus, PsycInfo, Embase, and CINAHL databases.

RESULTS

In 2022, we screened 15,248 reports to include 20 and extracted rates of mortality and primary outcomes in conventional care groups and intervention groups (involving initiatives to promote IPL in multidisciplinary teams). The meta-analysis of the 13 studies reporting mortality outcomes demonstrated that the 7166 patients in the intervention group had a significant 28% (95% confidence interval [CI], 40%-14%; P < 0.0003) reduced risk of dying compared with the 6809 patients in the conventional care group. The meta-analysis of the 14 studies reporting other treatment-related adverse outcomes demonstrated that the 4789 patients in the intervention group had a significant 23% (95% CI, 33%-12%; P < 0.0001) reduced risk of experiencing an adverse outcome during care compared with the 4129 patients in the conventional care group. Sensitivity analysis, involving the exclusion of the 20% of individual studies with the widest 95% CIs, confirmed the precision and reliability of our findings.

CONCLUSIONS

We believe that our results are the first to demonstrate significant quantitative evidence for the efficacy of IPL to translate into changes in clinical practice and improved patient outcomes. Our results reinforce earlier qualitative work of the value of IPL, but further prospective quantitative and mixed-methods research is needed to better define such benefits.

Diversity, inclusion, and equity at the British Journal of Anaesthesia: 100 years of progress

The past century, especially the past decade, has seen re-examination and evolution in our views about sex, gender, race, and ethnicity. The British Journal of Anaesthesia is part of an ongoing effort in research and medical publishing, and in health and education more generally, to improve diversity, inclusion, and equity. This editorial highlights the contributions and evolution of the Journal in these areas from its origin until today.

Discrimination and Dignity Experiences in Prior Oral Care Visits Predict Racialized Oral Health Inequities Among Nationally Representative US Adults

Racism, an oppressive and fallacious sociopolitical hierarchy, is a fundamental cause of oral health inequities worldwide. Everyday discrimination is associated with worse self-rated oral health, toothache and adult tooth loss, and lower oral care utilization. Few studies examine discrimination or microaggressions within oral care settings or their effects on oral health outcomes. We adapted the seven-item Everyday Discrimination Scale to the oral care setting (EDSOC); developed a four-item Dignity in Oral Care Scale (DOCS); fielded them to a probability-based nationally representative sample of US households as part of the 2022 State of Oral Health Equity in America survey (SOHEA, n = 5682); and examined associations between EDSOC and DOCS scores and three outcomes: self-rated oral health, duration since last oral care visit, and planning for future preventive/routine oral care. Nearly, all EDSCOC and DOCS measures were significantly associated with oral health outcomes. Discrimination experience in dental settings had an additive effect on reporting fair/poor oral health and a suppressive effect on planning a future dental visit. Indignity experience doubled-to-quadrupled the likelihood of reporting fair/poor oral health, not having visited a dentist in 2 years, and not planning a future oral care visit. Racio-ethnically minoritized patients may experience the unjust double bind of resolving urgent dental or completing preventive services needs amidst being treated in a discriminatory manner or without dignity. Oral health stakeholders should invest more effort to understand relationships between racism and oral health outcomes and introduce evidence-based interventions to ultimately abolish this societal harm.

The Gender of the Sender: Assessing Gender Biases of Greetings in Patient Portal Messages

Purpose: The purpose of the study was to determine if the use of professional titles in patient electronic health record (EHR) messages varied by gender of the physician receiving the message and gender of the patient sending the message. Methods: We conducted a retrospective observational study evaluating 285,744 messages for a patient's greeting to their physician. Logistic regression mixed effects models were fit to estimate the relationship between title use and gender. Results: Female physicians received 189,442 (66%), and female patients sent 183,579 (64%) messages. Female physicians received an average of 1754 messages each (sd = 1615, median [IQR] = 1624 [255-3040]), which was significantly more than the average 1235 messages for males (sd = 1527, median [IQR] = 385 [103-1857], Mann-Whitney-Wilcoxon p-value = 0.006). Female patients were more likely to send messages using professional titles (OR = 1.37, CI = 1.28-1.47, p < 0.001). Female physicians were no more likely than male physicians to receive professional titles (OR = 1.06, CI = 0.89-1.27, p = 0.500). Conclusions: Female physicians received significantly more EHR messages than men, and female patients were more likely to use a professional title when addressing their physician, regardless of gender. Across all patients, physician gender did not influence the rate of professional title used.

Data and model bias in artificial intelligence for healthcare applications in New Zealand

Introduction

Developments in Artificial Intelligence (AI) are adopted widely in healthcare. However, the introduction and use of AI may come with biases and disparities, resulting in concerns about healthcare access and outcomes for underrepresented indigenous populations. In New Zealand, Māori experience significant inequities in health compared to the non-Indigenous population. This research explores equity concepts and fairness measures concerning AI for healthcare in New Zealand.

Methods

This research considers data and model bias in NZ-based electronic health records (EHRs). Two very distinct NZ datasets are used in this research, one obtained from one hospital and another from multiple GP practices, where clinicians obtain both datasets. To ensure research equality and fair inclusion of Māori, we combine expertise in Artificial Intelligence (AI), New Zealand clinical context, and te ao Māori. The mitigation of inequity needs to be addressed in data collection, model development, and model deployment. In this paper, we analyze data and algorithmic bias concerning data collection and model development, training and testing using health data collected by experts. We use fairness measures such as disparate impact scores, equal opportunities and equalized odds to analyze tabular data. Furthermore, token frequencies, statistical significance testing and fairness measures for word embeddings, such as WEAT and WEFE frameworks, are used to analyze bias in free-form medical text. The AI model predictions are also explained using SHAP and LIME.

Results

This research analyzed fairness metrics for NZ EHRs while considering data and algorithmic bias. We show evidence of bias due to the changes made in algorithmic design. Furthermore, we observe unintentional bias due to the underlying pre-trained models used to represent text data. This research addresses some vital issues while opening up the need and opportunity for future research.

Discussions

This research takes early steps toward developing a model of socially responsible and fair AI for New Zealand's population. We provided an overview of reproducible concepts that can be adopted toward any NZ population data. Furthermore, we discuss the gaps and future research avenues that will enable more focused development of fairness measures suitable for the New Zealand population's needs and social structure. One of the primary focuses of this research was ensuring fair inclusions. As such, we combine expertise in AI, clinical knowledge, and the representation of indigenous populations. This inclusion of experts will be vital moving forward, proving a stepping stone toward the integration of AI for better outcomes in healthcare.

Quality improvement in New Zealand pediatric anesthesia: National quality direction, patient experience, equity, and collaboration

The current priorities of the quality and safety of patient care in New Zealand at a central government level are described, with a focus on equity and patient experience. Priorities between stakeholders differ. We report the current quality activities of New Zealand pediatric anesthetists in relation to these governance aims, seeking gaps and suggesting future directions to align governance priorities and local activities. International relevance is also outlined. New Zealand Māori experience health inequity. Complex systemic factors including those of systemic racism and prejudice contribute to the inequity. The specific contributions to health inequity from pediatric anesthetists are unknown but could include aspects of cultural safety, delays in treatment and treatment deficits. Patient experience is correlated positively with other quality domains. Peri-operative patient experience tools require outcomes of interest that matter to patients, including relevant cultural safety domains. Risk identification and critical event review contribute to local learnings in departments and institutions, and more widely to national and binational (with Australia) learnings. Several collaborative projects in Australia and New Zealand, whilst not primarily quality improvement projects, may improve pediatric anesthesia. These collaborations include a pediatric anesthesia professional network, a curriculum for a pediatric anesthetic fellowship, contributions to a document on standards for pediatric anesthesia, and a national quality group researching key performance indicators across New Zealand.