The effect of race and sex on physicians' recommendations for cardiac catheterization

Patient-Physician Racial Concordance Increases Likelihood of Total Knee Arthroplasty Recommendation

BACKGROUND

Minority patients have been shown to underutilize total knee arthroplasty (TKA) compared to non-Hispanic White patients. Specific drivers of this underutilization have not been identified. We sought to determine if racial concordance between patient and physician is associated with the surgeon's likelihood to recommend TKA.

METHODS

There were 402 patients who presented for management of knee osteoarthritis to the clinics of four fellowship-trained arthroplasty surgeons at a single academic center. We recorded the patient and surgeon's race/ethnicity as well as the physician-recommended treatment. Patient clinical data was input to the American Academy of Orthopaedic Surgeons (AAOS) appropriate use criteria website to generate a guideline-based procedure recommendation for TKA. Patients who were not appropriate for TKA based on AAOS guidelines were excluded from analyses to minimize selection bias. Chi-square and multivariable regression analyses evaluated the relationship between TKA recommendation by surgeon and physician-patient racial concordance.

RESULTS

Patients in this cohort who experienced racial concordance with their surgeon were more likely to receive a recommendation for TKA than patients who experienced racial discordance. Black patients who received racially concordant care were more likely to be offered surgery compared to those who received racially discordant care (55.1 versus 23.0%, P = 0.0001). The same effect was not observed in non-Hispanic White patients, where there was no significant difference in surgery offers between patients who received concordant versus discordant care (P = 0.18). Multivariable analyses were also conducted to test factors associated with TKA recommendations. Racial concordance was found to be an independent predictor of TKA recommendation while controlling for patient factors and individual differences by the surgeon.

CONCLUSIONS

Patients receiving racially concordant care in this cohort were more likely to be offered TKA, and the effect of racial concordance on TKA recommendation was greater among Black patients. These findings provide insight into possible drivers of TKA underutilization among minority groups.

Psychosocial stress and cardiovascular disease

Mahatma Gandhi once famously said: "poverty is the worst type of violence". He was referring to the state of political and social unrest that was pervading his nation, and the impact that humiliating defeat had on those who suffered in dire straits. Today, there is mounting evidence that social disparities cause intense psychosocial stress on those on whom they are imposed and can result in adverse cardiovascular outcomes. In modern society we still witness large disparities in living conditions between races, regions, continents and nations. Even in more privileged nations, we often witness the existence of "food and social deserts" in the middle of large urban centers. Sizable segments of the population are deprived of the comforts and privileges enjoyed by others; food quality and choices are limited, opportunities to exercise and play are scarce or unsafe, physical and verbal violence are prevalent, and racially driven conflicts are frequent. It has become apparent that these conditions predispose to the development of cardiovascular disease and affect its outcome negatively. Besides the increase in incidence of traditional risk factors, such as smoking, hypertension, insulin resistance and obesity, several other pathophysiological mechanisms involving the neuro-endocrine, inflammatory and immune pathways may be responsible for the noted negative outcomes. In this manuscript we review some of the evidence linking social distress with adverse cardiovascular outcomes and the potential subtending mechanisms and therapeutic interventions.

Building an Infrastructure to Address Racial Disparities in Treatment and Outcomes in Children with Type 1 Diabetes

Type 1 diabetes (T1D) is one of the most common chronic diseases in childhood and has many process and outcome metrics that reflect health care quality and clinical outcomes. When compared with non-Hispanic White children, non-Hispanic Black children are less likely to use diabetes technology and are more likely to have suboptimal diabetes control. To develop a meaningful and multi-pronged approach to addressing racial disparities in T1D, we need to understand the drivers of disparities from multiple perspectives. In this article, we describe an approach to integrating the perspectives of caregivers, clinical teams, and the clinical data infrastructure to address racial disparities in T1D.

Are those all my options? Evaluating oncologists' communication strategies in treatment and clinical trial discussions by race and gender

PURPOSE

Increasing patient enrollment and promoting equity in trial participation are essential to improving cancer care outcomes. Physicians play a crucial role in decision-making, making it important to understand communication strategies used by oncologists when discussing treatment options, including clinical trial participation.

METHODS

This observational qualitative study was conducted from 2022 to 2023. We recruited US medical oncologists who treat colon cancer and have access to clinical trials. Oncologists participated in simulated telehealth encounters with standardized patients with colon cancer who identified as Black or white and were referred to discuss treatment options, including a potential clinical trial.

RESULTS

Of 107 academic physicians contacted, 47 (44%) responded, and 21 (20%) participated. The median age was 41, 43% female, and 33% non-white. Average encounter length was 44:05 minutes. One to four treatment options were discussed. Clinical trials were discussed in nearly all conversations. Average duration of clinical trial-related talk was 08:30 minutes. Conversations with Black female patients were significantly shorter than with white female patients (mean difference: 7 minutes). Recommendations varied with 9/21 oncologists recommending a clinical trial, 9/21 deferring a decision, and 3/21 recommending standard of care. In the post-encounter survey, 86% of oncologists said they recommended a trial but only 43% actually did so.

CONCLUSION

Oncologists' communication about treatment options may impact patients' decisions and trial participation. In our study, fewer than half of oncologists recommended a trial with variability in how options were presented and the length of discussion. There was also a misperception with more oncologists thinking they recommended a trial, but they did not in the encounter. A more structured approach to these complex discussions may help oncologists communicate treatment options to patients in a more equitable and effective way.

Intersectional analysis for science and technology

Intersectionality describes interdependent systems of inequality related to sex, gender, race, age, class and other socio-political dimensions. By focusing on the compounded effects of social categories, intersectional analysis can enhance the accuracy and experimental efficiency of science. Here we extend intersectional approaches that were predominantly developed in the humanities, social sciences and public health to the fields of natural science and technology, where this type of analysis is less established. Informed by diverse global and disciplinary examples-from enhancing facial recognition for diverse user bases to mitigating the disproportionate impact of climate change on marginalized populations-we extract methods to demonstrate how quantitative intersectional analysis functions throughout the research process, from strategic considerations for establishing research priorities to formulating research questions, collecting and analysing data and interpreting results. Our goal is to offer a set of guidelines for researchers, peer-reviewed journals and funding agencies that facilitate systematic integration of intersectional analysis into relevant domains of science and technology. Precision in research best guides effective social and environmental policy aimed at achieving global equity and sustainability.

Disparities in troponin and ECG testing among emergency department patients with chest pain

BACKGROUND

Prior studies have highlighted disparities in the evaluation of chest pain based on patient race and sex. However, these studies were limited by small sample sizes and may not represent national practice patterns. This study evaluated differences in electrocardiogram (ECG) and troponin testing among emergency department (ED) patients presenting with chest pain or anginal-equivalent symptoms, focusing on variations by sex, race, ethnicity, and primary spoken language.

METHODS

A retrospective cohort study of patients presenting with chest pain or anginal-equivalent symptoms from 01/01/2016-12/31/2023 was conducted by searching the Epic Cosmos research platform separately for ECG and troponin testing. ECG and troponin testing rates were stratified and analyzed by age, sex, race, ethnicity, and primary language. Conditional logistic regression was used to calculate odds ratios (OR) with 95 % confidence intervals (CI).

RESULTS

Among 205,526,173 adult ED visits, 37,138,334 (18.1 %) met the inclusion criteria for chest pain or anginal-equivalent symptoms. For patients with full demographic data available, 30,648,879 of 36,672,008 (83.6 %) and 26,615,155 of 36,672,075 (72.6 %) underwent ECG and troponin testing, respectively. ECG testing was more frequent in male patients (OR:1.059; 95 %CI:1.058-1.060), Asian patients (OR:1.006; 95 %CI:1.004-1.009), and patients primarily speaking Spanish (OR:1.039; 95 %CI:1.040-1.042) or other non-English languages (OR:1.054; 95 %CI:1.051-1.056). However, it was less frequent among Black or African American patients (OR:0.955; 95 %CI:0.954-0.956) and individuals identifying as other races (OR:0.961; 95 %CI:0.959-0.963). Troponin testing was also more common in male patients (OR:1.087; 95 %CI:1.086-1.087) and those primarily speaking Spanish (OR:1.016; 95 %CI:1.014-1.019) or other non-English languages (OR:1.064; 95 %CI:1.061-1.067), but less common among Hispanic or Latino patients (OR:0.923; 95 %CI:0.921-0.924) and non-white patients (OR range:0.918-0.950).

CONCLUSIONS

Disparities in ECG and troponin testing were identified among ED patients presenting with chest pain or anginal-equivalent symptoms. Testing rates were lower in female and non-white patients, while patients primarily speaking non-English languages had higher testing rates.

Challenges Related to Out-of-Pocket Costs in Heart Failure Management

High out-of-pocket costs and financial toxicity related to heart failure treatment are substantial concerns. Two of 4 pillars of guideline-directed medical therapy for heart failure with reduced ejection fraction, for example, carry high costs that may attenuate their uptake. Furthermore, heart failure rarely occurs in isolation. Many patients have other comorbidities that require treatment, further driving up patients' out-of-pocket costs. Developing treatment plans that improve mortality without subjecting patients to financial toxicity can be challenging for several reasons. First, patients with heart failure can accrue out-of-pocket costs from multiple domains and can depend on a variety of insurance and pharmacy-related factors that can make determining patient-specific out-of-pocket cost estimates complicated. Second, strategies to mitigate financial toxicity involve health policy-level interventions and patient-level interventions. These have their own unique sets of challenges. Third, integrating out-of-pocket costs into shared decision-making requires nuanced and challenging discussions about whether a therapy is worth the cost. Though shared decision-making has been advocated, there are little data on how to best conduct these discussions. Health policies like the Inflation Reduction Act of 2022 may provide relief to some patients, and efforts to improve transparency have the potential to be beneficial. Over the long term, policy solutions such as value-based insurance design and patient engagement solutions that emphasize enhancing shared decision-making have important potential to yield durable results.

Do Socioeconomic Factors Affect Symptom Duration and Disease Severity at Presentation for Cubital Tunnel Syndrome?

BACKGROUND

Socioeconomic factors have been implicated in delayed presentation for compressive neuropathies of the upper extremity. Our article seeks to elucidate the effect of socioeconomic factors on self-reported symptom duration and objective disease severity at presentation for cubital tunnel syndrome.

METHODS

This retrospective cohort study included 207 patients with surgical management of cubital tunnel syndrome at 2 institutions between June 1, 2015, and March 1, 2020. Exclusion criteria included age under 18 years, revision surgery, lack of preoperative electrodiagnostic studies, and concurrent additional surgeries. Response variables were self-reported symptom duration, time from presentation to surgery, McGowan grade, and electrodiagnostic measures. Explanatory variables included age, sex, white race, diabetes mellitus, depression, anxiety, and the Distressed Communities Index.

RESULTS

Symptom duration was associated with nonwhite race, and time from presentation to surgery was associated with insurance provider. More clinically severe disease was associated with older age, male sex, and not having carpal tunnel syndrome. Nonrecordable sensory nerve action potential latency was associated with older age, higher body mass index, male sex, diabetes mellitus, and unemployment. Nonrecordable conduction velocities were associated with older age, and having fibrillations at presentation was associated with older age, male sex, and unemployment.

CONCLUSIONS

Economic distress is not associated with self-reported symptom duration, time from presentation to surgery, or presenting severity of cubital tunnel syndrome. White patients presented with shorter self-reported symptom duration. Insurance type was associated with delay from presentation to surgery. Older age and male sex were risk factors for more clinically severe disease at presentation.

Advancing Health Equity in the Cardiovascular Device Life Cycle

Despite advancements in diagnostics and therapeutics for cardiovascular disease, significant health disparities persist among patients from historically marginalized racial and ethnic groups, women, individuals who are socioeconomically under-resourced or underinsured, and those living in rural communities. While transcatheter interventions have revolutionized the treatment landscape in cardiology, populations bearing the greatest burden of disease continue to face inequitable access and poorer outcomes. A notable gap in the literature concerns the role of modern approaches to cardiovascular device innovation in shaping and perpetuating health disparities. Health equity has been declared one of the top strategic initiatives for 2022 to 2025 by the Food and Drug Administration Center for Devices and Radiological Health, underscoring the need for greater attention, dialogue, and targeted interventions in this space. This narrative review uses the cardiovascular device life cycle as a conceptual framework to enhance understanding and guide future efforts to mitigate disparities in the field of interventional cardiology. Drawing on illustrative examples from interventional cardiology, we examine current practices in cardiovascular device regulation and approval, clinical trial evaluation, adoption patterns, and postprocedural outcomes with the aim of uncovering potential mechanisms of disparities and identifying opportunities for targeted interventions.

Implicit Racial Bias and Unintentional Harm in Vascular Care

Importance

Implicit bias may influence physician treatment decisions and contribute to Black-White health disparities. There are limited data linking implicit bias with actual care delivery and outcomes.

Objective

To determine whether implicit racial bias is associated with potentially harmful surgical treatment selection for a cohort of patients with peripheral artery disease-related claudication.

Design, Setting, and Participants

This survey study, linked with observational registry data, included eligible clinicians who participate in the Vascular Quality Initiative (VQI) among 960 centers. The VQI includes academic medical centers, teaching hospitals, community hospitals, and private practices. Eligible participants included all vascular specialist VQI members (N = 2512), of whom 218 completed the race implicit association test (IAT) and were linkable to procedure-level data. The study was conducted between October 2021 and October 2022.

Exposure

Race IAT.

Main Outcomes and Measures

Clinician-level implicit bias results were linked to patient-level registry data of peripheral revascularization procedures performed for claudication. The adjusted odds of performance of any infrapopliteal procedure by specialist implicit bias and patient race were measured via mixed-effects logistic regression models. Implicit bias as a moderator of the association of infrapopliteal procedures for claudication and patient race with 1-year amputation was assessed as a secondary outcome.

Results

Among 218 vascular specialists (mean [SD] age, 46 [9] years; 160 [73%] male), 157 (72%) had a pro-White bias. Black patients treated by a physician with pro-White bias had a significant increase in the odds of receiving an infrapopliteal procedure compared with the total sample (adjusted odds ratio [AOR], 1.67; 95% CI, 1.12-2.48). When treated by a specialist with pro-White bias, Black patients had increased odds of 1-year amputation, regardless of anatomic location treated, compared with White patients (AOR, 2.34; 95% CI, 1.20-4.55). Conversely, Black patients treated by a specialist with no bias had similar odds of an infrapopliteal procedure (AOR, 0.93; 95% CI, 0.68-1.26) as the full patient sample and similar odds of 1-year amputation (AOR, 1.29; 95% CI, 0.33-4.99) as White patients.

Conclusions and Relevance

These findings indicate that implicit bias is associated with potentially harmful infrapopliteal procedures for Black patients and contributes to Black-White outcome disparities in the US. These results suggest the need for system-level interventions that transparently identify and warn of procedures not aligned with best practices to reduce the negative influence of implicit bias.

Diversity-Focused Undergraduate Premedical Enrichment Programs: The Impact of Research Experiences

Purpose

Many diversity-focused, premedical enrichment programs anchor around a mentored research experience. Data, however, are lacking on how participation in mentored biomedical research in these program impacts participants' subsequent medical student experience. To begin to address this gap, a cohort of first year medical students who had matriculated through a diversity-focused premedical enrichment programs was queried about the impact of their previous research experiences and their perceptions regarding medical school related research.

Methods

This mixed methods study involved 10 first year medical students from groups underrepresented in medicine (URiM) who had matriculated to the Perelman School of Medical School of Medicine through the Penn Access Summer Scholars (PASS Program) and 10 non-URiM first year peers. At the start of medical school and after their first year, participants completed structured interviews and Likert style surveys to assess the impact of their pre-medical school research experiences and their current beliefs about the significance of research experiences to their medical education.

Results

The quantitative analyses of the survey data demonstrated that the PASS and the non-PASS students were similar in their attitudes, beliefs, and assessments of their research competence. In contrast, qualitative analyses of the interviews offered a more nuanced picture of the differences and similarities between the two groups. The PASS students expressed more confidence in their research skills and felt better able to establish and maintain connections with mentors compared to their non-PASS peers. Both groups of students, however, expressed frustration at the lack of identity-concordant mentors to support their research aspirations and felt the pressure to do research to support their competitiveness for the residency match.

Conclusion

The research experiences of diversity-focused enrichment programs may foster the agency and self-efficacy of participants in ways that support their success in medical school.

Algorithmic individual fairness and healthcare: a scoping review

Objectives

Statistical and artificial intelligence algorithms are increasingly being developed for use in healthcare. These algorithms may reflect biases that magnify disparities in clinical care, and there is a growing need for understanding how algorithmic biases can be mitigated in pursuit of algorithmic fairness. We conducted a scoping review on algorithmic individual fairness (IF) to understand the current state of research in the metrics and methods developed to achieve IF and their applications in healthcare.

Materials and Methods

We searched four databases: PubMed, ACM Digital Library, IEEE Xplore, and medRxiv for algorithmic IF metrics, algorithmic bias mitigation, and healthcare applications. Our search was restricted to articles published between January 2013 and November 2024. We identified 2498 articles through database searches and seven additional articles, of which 32 articles were included in the review. Data from the selected articles were extracted, and the findings were synthesized.

Results

Based on the 32 articles in the review, we identified several themes, including philosophical underpinnings of fairness, IF metrics, mitigation methods for achieving IF, implications of achieving IF on group fairness and vice versa, and applications of IF in healthcare.

Discussion

We find that research of IF is still in their early stages, particularly in healthcare, as evidenced by the limited number of relevant articles published between 2013 and 2024. While healthcare applications of IF remain sparse, growth has been steady in number of publications since 2012. The limitations of group fairness further emphasize the need for alternative approaches like IF. However, IF itself is not without challenges, including subjective definitions of similarity and potential bias encoding from data-driven methods. These findings, coupled with the limitations of the review process, underscore the need for more comprehensive research on the evolution of IF metrics and definitions to advance this promising field.

Conclusion

While significant work has been done on algorithmic IF in recent years, the definition, use, and study of IF remain in their infancy, especially in healthcare. Future research is needed to comprehensively apply and evaluate IF in healthcare.

Non-Medical Characteristics Affect Referral for Advanced Heart Failure Services: a Retrospective Review

BACKGROUND

Patients with advanced heart failure (AHF) are extensively evaluated before heart transplantation or left ventricular assist device (LVAD) eligibility. Patients are assessed for medical need and psychosocial or economic factors that may affect success post-treatment. For patients to be evaluated, however, they first must be referred. This study investigated social and economic factors affecting AHF referral, specialist visits, or treatment.

METHODS

Patients with heart failure (n = 24,258) were reviewed at one large hospital system over 4 years. Independent variables age, sex, marital status, race/ethnicity, preferred language, smoking, and insurance status were assessed for the outcomes of referral, clinic visit, and treatment by Chi-square and ANOVA. In-house and 1-year mortality were evaluated by logistic regression, and time-to-event was assessed by the Cox proportional hazards model.

RESULTS

Younger (HR 0.934, 95% CI 0.925-0.943), male (HR 2.216, 95% CI 1.544-3.181), and publicly insured (HR 1.298 [95% CI 1.038, 1.623]) patients were more likely to be referred, while unmarried (HR 0.665, 95% CI 0.488-0.905) and smoking (HR 0.549, 95% CI 0.389-0.776) patients had fewer referrals. Younger, married, and nonsmoking patients were more likely to have a clinic visit. Younger age, White race, and Hispanic/Latino ethnicity were associated with receiving a heart transplant, and LVAD recipients were more likely Hispanic/Latino ethnicity. Advanced age, Hispanic/Latino ethnicity, and smoking were associated with 1-year mortality after heart failure diagnosis.

CONCLUSIONS

Disparities in access exist before evaluation for AHF therapies. Improving access at the levels of referral and evaluation is a necessary step toward achieving equity in organ allocation.

Cardio-Oncology and Heart Failure: a Scientific Statement From the Heart Failure Society of America

Heart failure and cancer remain 2 of the leading causes of morbidity and mortality, and the 2 disease entities are linked in a complex manner. Patients with cancer are at increased risk of cardiovascular complications related to the cancer therapies. The presence of cardiomyopathy or heart failure in a patient with new cancer diagnosis portends a high risk for adverse oncology and cardiovascular outcomes. With the rapid growth of cancer therapies, many of which interfere with cardiovascular homeostasis, heart failure practitioners need to be familiar with prevention, risk stratification, diagnosis, and management strategies in cardio-oncology. This Heart Failure Society of America statement addresses the complexities of heart failure care among patients with active cancer diagnoses and cancer survivors. Risk stratification, monitoring and management of cardiotoxicity are presented across stages A through D heart failure, with focused discussion on heart failure with preserved ejection fraction and special populations, such as survivors of childhood and young-adulthood cancers. We provide an overview of the shared risk factors between cancer and heart failure, highlighting heart failure as a form of cardiotoxicity associated with many different cancer therapeutics. Finally, we discuss disparities in the care of patients with cancer and cardiac disease and present a framework for a multidisciplinary-team approach and critical collaboration among heart failure, oncology, palliative care, pharmacy, and nursing teams in the management of these complex patients.

Evaluation of sex differences in the receipt of concomitant atrial fibrillation procedures during nonmitral cardiac surgery

OBJECTIVE

Women are less likely to receive guideline-recommended cardiovascular care, but evaluation of sex-based disparities in cardiac surgical procedures is limited. Receipt of concomitant atrial fibrillation (AF) procedures during nonmitral cardiac surgery was compared by sex for patients with preoperative AF.

METHODS

Patients with preoperative AF undergoing coronary artery bypass grafting and/or aortic valve replacement at any of the 33 hospitals in Michigan from 2014 to 2022 were included. Patients with prior cardiac surgery, transcatheter AF procedure, or emergency/salvage status were excluded. Hierarchical logistic regression identified predictors of concomitant AF procedures, account for hospital and surgeon as random effects.

RESULTS

Of 5460 patients with preoperative AF undergoing nonmitral cardiac surgery, 24% (n = 1291) were women with a mean age of 71 years. Women were more likely to have paroxysmal (vs persistent) AF than men (80% vs 72%; P < .001) and had a higher mean predicted risk of mortality (5% vs 3%; P < .001). The unadjusted rate of concomitant AF procedure was 59% for women and 67% for men (P < .001). After risk adjustment, women had 26% lower adjusted odds of concomitant AF procedure than men (adjusted odds ratio, 0.74; 95% CI, 0.64-0.86; P < .001). Female sex was the risk factor associated with the lowest odds of concomitant AF procedure.

CONCLUSIONS

Women are less likely to receive guideline recommended concomitant AF procedure during nonmitral surgery. Identification of barriers to concomitant AF procedure in women may improve treatment of AF.

Failure to Rescue Female Patients Undergoing High-Risk Surgery

Importance

Female patients have higher mortality rates after high-risk surgery than male patients. It is unknown whether this mortality gap is due to different rates of postoperative complications or if complications are addressed differently by sex, causing complications to lead to death-so-called failure to rescue.

Objective

To evaluate sex differences in failure to rescue across high-risk surgical procedures.

Design, Setting, and Participants

This retrospective cohort study was conducted using data from Medicare beneficiaries from October 2015 to February 2020 who underwent high-risk vascular or cardiac surgical procedures, including abdominal aortic aneurysm repair, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement or repair. Data analysis was performed from August 2023 to March 2024.

Exposures

The primary exposure was patient sex.

Main Outcomes and Measures

The primary outcomes were risk-adjusted rates of complications, 30-day mortality, and failure to rescue, which was defined as a death occurring after a serious complication. Categorical variables are presented as frequencies and proportions and compared using χ2 analysis. Continuous variables were tested for normality and compared using a t test.

Results

A total of 863 305 Medicare beneficiaries were included in this study cohort, of whom 304 176 (35.2%) were female. Mean (SD) age was slightly higher in female patients (74.8 [9.3] years) than male patients (73.4 [8.5] years), and female patients had more comorbidities than male patients (≥2 Elixhauser comorbidities, female: 262 809 [86.4%] vs male: 465 231 [83.2%]). Female patients were more likely to receive care at large hospitals and hospitals with a higher surgical case volume. Overall, female and male patients had similar rates of complications (female: 14.98% vs male: 14.37%; adjusted relative risk [aRR], 1.04; 95% CI, 1.03-1.05; P < .001). However, female patients had higher rates of 30-day mortality (female: 4.22% vs male: 3.34%; aRR, 1.26; 95% CI, 1.23-1.29; P < .001) and higher rates of failure to rescue (female: 10.71% vs male: 8.58%; aRR, 1.25; 95% CI, 1.22-1.28; P < .001). A similar pattern was observed when stratified by each procedure.

Conclusions and Relevance

In this cohort study among Medicare beneficiaries undergoing high-risk surgery, male and female patients experienced similar rates of serious complications, but female patients with complications were more likely to die. In other words, clinicians fail to rescue female patients with complications after high-risk surgery more often than male patients. Improving the recognition and management of female patients' complications postoperatively may narrow the sex disparity after high-risk surgery.

Navigating Hostile Workplaces and Educational Spaces Within Health Services and Policy Research

Introduction

The representation of ethnoracial minoritized individuals in health services and policy research (HSPR) has increased in recent years. However, previous literature has exposed a need to acknowledge and attend to inequities within the HSPR workforce.

Methods

To describe educational and workplace experiences that characterize diversity, equity, and inclusion (DEI) within the HSPR profession. In this qualitative study, six focus groups were conducted virtually via Zoom with 27 individuals who reported working or pursuing higher education in HSPR from December 2020 to January 2021. We sought HSPRers perspectives on DEI initiatives, work and educational environments, experiences, and climate, and recommendations for improving DEI in HSPR. We developed a structured codebook and applied a deductive approach to conduct thematic analysis.

Results

Of the 27 participants, nearly half of participants identified as Black/African American (44%); most were women (81%). Three major themes emerged: (1) HSPR work and education spaces subject minoritized HSPRs to a range of exclusionary and harmful practices; (2) DEI initiatives fail to address the need for institutional change; and (3) by working with and for policymakers, HSPRs are uniquely subjected to shifting political contexts that reinforce racism.

Discussion

Despite an increasing commitment to increasing the diversity of the HSPR workforce and improving equity and inclusion in the HSPR workplace, the findings suggest that more intentional and action-oriented work is needed, especially work that emphasizes inclusion and equity across various levels of the workplace.

Health Equity Implications

The findings offer critical insight on necessary workplace and educational reform to develop the workforce necessary to advance population health equity and equity-oriented policy making.

Biased Language in Simulated Handoffs and Clinician Recall and Attitudes

Importance

Poor-quality handoffs can lead to medical errors when transitioning patient care. Biased language within handoffs may contribute to errors and lead to disparities in health care delivery.

Objective

To compare clinical information recall accuracy and attitudes toward patients among trainees in paired cases of biased vs neutral language in simulated handoffs.

Design, Setting, and Participants

Surveys administered from April 29 to June 15 and from July 20 to October 10, 2023, included 3 simulated verbal handoffs, randomized between biased and neutral, and measured clinical information recall, attitudes toward patients, and key takeaways after each handoff. Participants included residents in internal medicine, pediatrics, and internal medicine-pediatrics and senior medical students at 2 academic medical centers in different geographic regions of the US. Data were analyzed from November 2023 to June 2024.

Exposures

Each participant received 3 handoffs that were based on real handoffs about Black patients at 1 academic center. These handoffs were each randomized to either a biased or neutral version. Biased handoffs had 1 of 3 types of bias: stereotype, blame, or doubt. The order of handoff presentation was also randomized. Internal medicine and pediatrics residents received slightly different surveys, tailored for their specialty. Internal medicine-pediatrics residents received the pediatric survey. Medical students were randomly assigned the survey type.

Main Outcomes and Measures

Each handoff was followed by a clinical information recall question, an adapted version of the Provider Attitudes Toward Sickle Cell Patients Scale (PASS), and 3 free-response takeaways.

Results

Of 748 trainees contacted, 169 participants (142 residents and 27 medical students) completed the survey (23% overall response rate), distributed across institutions, residency programs, and years of training (95 female [56%]; mean [SD] age, 28.6 [2.3] years). Participants who received handoffs with blame-based bias had less accurate information recall than those who received neutral handoffs (77% vs 93%; P = .005). Those who reported bias as a key takeaway of the handoff had lower clinical information recall accuracy than those who did not (85% vs 93%; P = .01). Participants had less positive attitudes toward patients per PASS scores after receiving biased compared with neutral handoffs (mean scores, 22.9 [3.3] vs 25.2 [2.7]; P < .001). More positive attitudes toward patients were associated with higher clinical information recall accuracy (odds ratio, 1.12; 95% CI, 1.02-1.22).

Conclusions and Relevance

In this survey study of residents and medical students, biased handoffs impeded accurate transfer of key clinical information and decreased empathy, potentially endangering patients and worsening health disparities. Handoff standardization is critical to addressing racial bias and improving patient safety.

Healthcare providers' psychological investment in clinical recommendations: Investigating the role of implicit racial attitudes

Racial disparities in clinical recommendations can result in racial disparities in health. While healthcare providers' implicit racial attitudes (affective component of bias) are theorized to be one major factor contributing to racial disparities in clinical recommendations, empirical evidence to support the link is lacking. This study aimed to bridge this gap by moving beyond the standard approach of operationalizing the quality of clinical recommendations as a guideline-consistent vs. -inconsistent dichotomy. The present secondary study examined the role of provider implicit racial attitudes in the quality of clinical recommendations, operationalized as behaviors reflecting providers' psychological investment in patient care (i.e., number of words used to describe clinical recommendations, and number of treatment options recommended). Two-hundred-and-ten White medical trainees reviewed a clinical vignette of either a White or Black male patient and provided clinical recommendations. Their implicit racial attitudes were evaluated using the Implicit Association Test. Participants with more biased implicit racial attitudes (i.e., stronger implicit preference for White vs. Black individuals) used fewer words to describe their clinical recommendations and provided fewer clinical recommendations for the Black (vs. White) patient, while there were no significant differences between Black and White patients among participants with less biased implicit racial attitudes. These results illustrate the insidious impact of implicit racial attitudes in healthcare provision and underscore the need for researchers to consider the complex, nuanced ways in which provider implicit racial attitudes might manifest in clinical decision-making.

Elevating equity: advancing diversity and inclusivity through trialing bias reduction tools in the general internal medicine program resident application process

BACKGROUND

Decades of medical data show worse patient outcomes among racial and gender minorities due to implicit, explicit, and structural biases. Increasing representation of marginalized groups among care providers is imperative to help address this. Limited literature exists on bias awareness strategies for interviewers during the selection of applicants to General Internal Medicine (GIM) programs in Canada. This study examines the trial of bias reduction tools to increase interviewers' awareness of implicit biases.

METHODS

The Model of Improvement framework guided the trail of an instructional video, the adapted implicit association test (IAT), and a paper awareness tool (PAT) to increase interviewers' awareness of implicit biases during the University of Alberta's GIM applicant selection. An anonymous online survey was disseminated to physician interviewers. Descriptive statistics (percentages) and a modified sentiment analysis was completed.

RESULTS

10 of 14 interviewers completed the survey. Respondents reported an increased awareness of using bias reduction tools (IAT, 25%; video, 71%; PAT, 67%) to inform them on their implicit biases. The future use of IAT, video, and PAT was supported by 50%, 71%, and 67% of interviewers, respectively.

CONCLUSIONS

Interviewers prefer the instructional video and PAT over the IAT. Textual responses suggest existing concerns for biases inherent to the interview process yet 70% (7/10) of respondents believe that interviews should have a weighting of 50% towards final ranking of candidates. As many institutions continue to rely on interviews to evaluate candidates, our findings indicate the need for a national study to develop a framework to mitigate inherent biases during interviewing of candidates.

"Against Medical Advice" Discharges After Respiratory-Related Hospitalizations: Strategies for Respectful Care

Against medical advice (AMA) discharges are practically and emotionally challenging for both patients and clinicians. Moreover, they are common after admissions for respiratory conditions such as COPD and asthma, and they are associated with poor outcomes. Despite the challenges presented by AMA discharges, clinicians rarely receive formal education and have limited guidance on how to approach these discharges. Often, the approach to AMA discharges prioritizes designating the discharge as "AMA," whereas effective coordination of discharge care receives less attention. Such an approach can lead to stigmatization of patients and low-quality care. Although evidence for best practices in AMA discharges remains lacking, we propose a set of strategies to improve care in AMA discharges by focusing on respect, in which clinicians treat patients as equals and honor differing values. We describe five strategies, including (1) preventing an AMA discharge; (2) conducting a patient-centered and truthful discussion of risk; (3) providing harm-reducing discharge care; (4) minimizing stigma and bias; and (5) educating trainees. Through a case of a patient discharging AMA after a COPD exacerbation, we highlight how these strategies can be applied to common issues in respiratory-related hospitalizations, such as prescribing inhalers and managing oxygen requirements. We argue that, by using these strategies, clinicians can deliver more respectful and higher quality care to an often-marginalized population of patients with respiratory disease.

Hidden: A Baker's Dozen Ways in Which Research Reporting is Less Transparent than it Could be and Suggestions for Implementing Einstein's Dictum

The tutelage of our mentors as scientists included the analogy that writing a good scientific paper was an exercise in storytelling that omitted unessential details that did not move the story forward or that detracted from the overall message. However, the advice to not get lost in the details had an important flaw. In science, it is the many details of the data themselves and the methods used to generate and analyze them that give conclusions their probative meaning. Facts may sometimes slow or distract from the clarity, tidiness, intrigue, or flow of the narrative, but nevertheless they are important for the assessment of what was done, the trustworthiness of the science, and the meaning of the findings. Nevertheless, many critical elements and facts about research studies may be omitted from the narrative and become hidden from scholarly scrutiny. We describe a "baker's dozen" shortfalls in which such elements that are pertinent to evaluating the validity of scientific studies are sometimes hidden in reports of the work. Such shortfalls may be intentional or unintentional or lie somewhere in between. Additionally, shortfalls may occur at the level of the individual or an institution or of the entire system itself. We conclude by proposing countermeasures to these shortfalls.

Race, Ethnicity, and Gender Disparities in Management and Outcomes of Critically Ill Adults with Sepsis

Critical care pathologies are not immune to potential social challenges in both health equity and health disparities. Over the last century, as sepsis physiology and interventions have continued to improve clinical outcomes, recognition that such improvements are not seen in all diverse populations warrants an understanding of this disproportionate success. In this review, the authors evaluate sepsis incidence and outcomes across ethnicity, race, and sex and gender, taking into account social and biological categorization and the association of sepsis-related mortality and morbidity. Further, the authors review how such issues transcend across age groups, with vulnerability to sepsis.

Virtual reality evidence on the impact of physicians' open versus defensive communication on patients

Using virtual reality (VR) in an experimental setting, we analyse how communicating more openly about a medical incident influences patients' feelings and behavioural intentions. Using VR headsets, participants were immersed in an actual hospital room where they were told by a physician that a medical incident had occurred. In a given scenario, half of the participants were confronted by a physician who communicated openly about the medical incident, while the other half were confronted with the exact same scenario except that the physician employed a very defensive communication strategy. The employed technology allowed us to keep everything else in the environment constant. Participants exposed to open disclosure were significantly more likely to take further steps (such as contacting a lawyer to discuss options and filing a complaint against the hospital) and express more feelings of blame against the physician. At the same time, these participants rated the physician's communication skills and general impression more highly than those who were confronted with a defensive physician. Nevertheless, communicating openly about the medical incident does not affect trust in the physician and his competence, perceived incident severity and likelihood of changing physician and filing suit.

Developing methods to identify resilience and improve communication about diagnosis in pediatric primary care

Communication underlies every stage of the diagnostic process. The Dialog Study aims to characterize the pediatric diagnostic journey, focusing on communication as a source of resilience, in order to ultimately develop and test the efficacy of a structured patient-centered communication intervention in improving outpatient diagnostic safety. In this manuscript, we will describe protocols, data collection instruments, methods, analytic approaches, and theoretical frameworks to be used in to characterize the patient journey in the Dialog Study. Our approach to characterization of the patient journey will attend to patient and structural factors, like race and racism, and language and language access, before developing interventions. Our mixed-methods approach is informed by the Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 framework (which describes the sociotechnical system underpinning diagnoses within the broader context of multiple interactions with different care settings over time) and the Safety II framework (which seeks to understand successful and unsuccessful adaptations to ongoing changes in demand and capacity within the healthcare system). We will assess the validity of different methods to detect diagnostic errors along the diagnostic journey. In doing so, we will emphasize the importance of viewing the diagnostic process as the product of communications situated in systems-of-work that are constantly adapting to everyday challenges.

Depression Part 2: Treatment

Depression treatment strategies are within the scope of pediatric practice and among the competencies recommended by the Academy of Pediatrics and The American Board of Pediatrics. Treatments that may be provided through collaborative care include nonpharmacologic therapies such as psychosocial treatments and evidence-based psychotherapies, and pharmacotherapy and monitoring processes for depression. Abundant support and guidance are available to pediatricians in depression care, including mental health consultation and online materials.

Depression Part 1: Evaluation

By young adulthood, 1 in 5 teens will experience an episode of major depression. The second leading cause of death among youths aged 15 to 24 years is suicide, most of which will have been caused by untreated or undiagnosed depression. Depression is a highly heritable condition: depressed children often have depressed parents. Support to caregivers is important because depressed parents can have negative effects on children's development and future mental health. Groups more vulnerable to mental health disorders such as depression include Black, Indigenous, and persons of color and lesbian, gay, bisexual, transgender, or queer/questioning, who in recent years have the highest rate of suicide attempts (Black teens, sexual minority youth), the highest increases in suicide rates (Black children and youths), and the highest suicide rates (American Indian/Alaskan native). They frequently experience more adverse childhood events, which increases the risk of depression and suicide attempts. Pediatricians are most likely to care for these vulnerable youths, who often are less engaged in specialty mental health care for a variety of reasons, including stigma and barriers to access. By offering behavioral and mental health care to vulnerable populations in primary care, mental health equity may be achieved. Screening for depression and assessment for suicide are within the scope of pediatric practice and among the competencies recommended by the American Academy of Pediatrics and The American Board of Pediatrics.

Temporal trends of health disparity in the utilization of curative-intent treatments for hepatocellular carcinoma: are we making progress?

BACKGROUND

Liver-directed treatments - ablative therapy (AT), surgical resection (SR), liver transplantation (LT), and transarterial chemoembolization (TACE) - improve the overall survival of patients with early-stage hepatocellular carcinoma (HCC). Although racial and socioeconomic disparities affect access to liver-directed therapies, the temporal trends for the curative-intent treatment of HCC remain to be elucidated.

METHODS

This study performed chi-square, logistic regression, and temporal trends analyses on data from the Nationwide Inpatient Sample from 2011 to 2019. The outcome of interest was the rate of AT, SR, LT (curative-intent treatments), and TACE utilization, and the primary predictors were racial/ethnic group and socioeconomic status (SES; insurance status).

RESULTS

African American and Hispanic patients had lower odds of receiving AT (African American: odds ratio [OR], 0.78; P < .001; Hispanic: OR, 0.84; P = .005) and SR (African American: OR, 0.71; P < .001; Hispanics: OR, 0.64; P < .001) than White patients. Compared with White patients, the odds of LT was lower in African American patients (OR, 0.76; P < .001) but higher in Hispanic patients (OR, 1.25; P = .001). Low SES was associated with worse odds of AT (OR, 0.79; P = .001), SR (OR, 0.66; P < .001), and LT (OR, 0.84; P = .028) compared with high SES. Although curative-intent treatments showed significant upward temporal trends among White patients (10.6%-13.9%; P < .001) and Asian and Pacific Islander/other patients (14.4%-15.7%; P = .007), there were nonsignificant trends among African American patients (10.9%-10.1%; P = .825) or Hispanic patients (12.2%-13.7%; P = .056).

CONCLUSION

Our study demonstrated concerning disparities in the utilization of curative-intent treatment for HCC based on race/ethnicity and SES. Moreover, racial/ethnic disparities have widened rather than improved over time.

Effects of patient gender, ethnicity, and socioeconomic status on psychiatric assessments: A vignette-based experimental study

OBJECTIVE

To investigate whether information about the gender, ethnicity, and socioeconomic status of the patient affects psychiatric assessments in a sample of practicing clinicians in Swedish adult psychiatry.

METHOD

The study used an experimental design in which vignettes describing patients were identical except for information regarding their gender, ethnicity, and socioeconomic status. The outcome variables included assessments of the severity of the patient's clinical condition, how dangerous the patient was to themselves and others, the likelihood of reporting to social services (due to concern for the welfare of children), and whether the patient was recommended psychotherapy or psychopharmaceutical treatment.

RESULTS

A series of ANOVAs were performed to investigate main and interaction effects of the studied variables. The performed analyses identified several instances in which the clinicians' assessments varied as a function of the social categories under investigation. For example, male patients and "Arab Swedish" patients were perceived as more dangerous, "Arab Swedish" patients, male patients, and patients with low socioeconomic status were less likely to be recommended psychotherapy, and "Arab Swedish" patients were more likely to be reported to social services. The effect sizes were generally small.

CONCLUSIONS

The study provides support for the suggestion that information regarding patient gender, ethnicity, and socioeconomic status affects central aspects of psychiatric assessments. The results are interpreted and discussed in relation to other studies on the influence of social stereotypes on psychiatric assessments and the practice of clinical psychiatric assessments.

How do we treat our male and female patients? - A primer on gender-based health care inequities

Health is a fundamental human right, yet disparities in healthcare, based on gender, persist for women. These inequities stem from a patriarchal society that has regarded men as the default standard, leading to women being treated merely as smaller men. Contributing to these disparities are the gender stereotypes that pervade our society. Women possess differences in anatomy, physiology, psychology and social experience than men. To achieve health equity, it is vital to understand and be open to consider and evaluate these aspects in each individual patient. This requires an understanding of our own biases and a commitment to valuing diversity in both patient and caregiver. Improving equity and diversity throughout all aspects of the medical system will be necessary to provide optimal patient care for all.

Feedback Loop Failure Modes in Medical Diagnosis: How Biases Can Emerge and Be Reinforced

BACKGROUND

Medical diagnosis in practice connects to research through continuous feedback loops: Studies of diagnosed cases shape our understanding of disease, which shapes future diagnostic practice. Without accounting for an imperfect and complex diagnostic process in which some cases are more likely to be diagnosed correctly (or diagnosed at all), the feedback loop can inadvertently exacerbate future diagnostic errors and biases.

FRAMEWORK

A feedback loop failure occurs if misleading evidence about disease etiology encourages systematic errors that self-perpetuate, compromising future diagnoses and patient care. This article defines scenarios for feedback loop failure in medical diagnosis.

DESIGN

Through simulated cases, we characterize how disease incidence, presentation, and risk factors can be misunderstood when observational data are summarized naive to biases arising from diagnostic error. A fourth simulation extends to a progressive disease.

RESULTS

When severe cases of a disease are diagnosed more readily, less severe cases go undiagnosed, increasingly leading to underestimation of the prevalence and heterogeneity of the disease presentation. Observed differences in incidence and symptoms between demographic groups may be driven by differences in risk, presentation, the diagnostic process itself, or a combination of these. We suggested how perceptions about risk factors and representativeness may drive the likelihood of diagnosis. Differing diagnosis rates between patient groups can feed back to increasingly greater diagnostic errors and disparities in the timing of diagnosis and treatment.

CONCLUSIONS

A feedback loop between past data and future medical practice may seem obviously beneficial. However, under plausible scenarios, poorly implemented feedback loops can degrade care. Direct summaries from observational data based on diagnosed individuals may be misleading, especially concerning those symptoms and risk factors that influence the diagnostic process itself.

HIGHLIGHTS

Current evidence about a disease can (and should) influence the diagnostic process. A feedback loop failure may occur if biased "evidence" encourages diagnostic errors, leading to future errors in the evidence base.When diagnostic accuracy varies for mild versus severe cases or between demographic groups, incorrect conclusions about disease prevalence and presentation will result without specifically accounting for such variability.Use of demographic characteristics in the diagnostic process should be done with careful justification, in particular avoiding potential cognitive biases and overcorrection.

Healthcare Disparities in Cardiovascular Medicine

There are significant healthcare disparities in cardiovascular medicine that represent a challenge for cardiologists and healthcare policy-makers who wish to provide equitable care. Disparities exist in both the management and outcomes of hypertension, coronary artery disease and its sequelae, and heart failure. These disparities are present along the lines of race, gender, and socioeconomic status. Despite recent efforts to reduce disparity, there are knowledge and research gaps among cardiologists with regards to both the scope of the problem and how to solve it. Solutions include increasing awareness of disparities in cardiovascular health, increasing research for optimal treatment of underserved communities, and public policy changes that reduce disparities in social determinants of health.

Enrollment of Black, Indigenous and People of Color (BIPOC) and female participants in the US diabetes trials spanning 2000 to 2020: A chronological survey

AIMS

Little is known about the enrollment practice of both Black, Indigenous and People of Color (BIPOC) and females in the US diabetes trials. We aimed to perform a chronological survey to evaluate the enrollment of BIPOC and female participants in the US diabetes randomized controlled trials (RCTs) over the past two decades.

METHODS

We searched databases to systematically include the US diabetes RCTs from 2000 January 1st to 2020 December 31st. Primary outcome was the adequate enrollment of both BIPOC and females, defined by the participation to prevalence ratio (PPR) > 0.8. We tested the temporal trend in adequate enrollment over time and used logistic regression analysis to explore the relationship between adequate enrollment and trial characteristics.

RESULTS

A total of 69 US diabetes trials were included for analyses, with a median BIPOC and female enrollment percentage of 29.0 % and 45.4 % respectively. There were 22 (31.9 %) trials with adequate enrollment of both BIPOC and females. No significant trend of adequate enrollment percentage of BIPOC and females over time was observed (P = 0.16). Of trial types, those with medication interventions were significantly related to decreased odds of adequate enrollment, when compared to trials with non-drug interventions (odds ratio = 0.29, 95 % confidence interval: 0.11-0.84).

CONCLUSIONS

Less than one third of the US diabetes trials adequately enrolled both BIPOC and females over the past two decades, and no temporal improvement in BIPOC and female participant enrollment was observed. These results highlight the need for more endeavors to mitigate inadequate representation regarding BIPOC and female enrollment in diabetes trials.

Subjective cognitive concerns, APOE ε4, PTSD symptoms, and risk for dementia among older veterans

BACKGROUND

Posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) are associated with self-reported problems with cognition as well as risk for Alzheimer's disease and related dementias (ADRD). Overlapping symptom profiles observed in cognitive disorders, psychiatric disorders, and environmental exposures (e.g., head injury) can complicate the detection of early signs of ADRD. The interplay between PTSD, head injury, subjective (self-reported) cognitive concerns and genetic risk for ADRD is also not well understood, particularly in diverse ancestry groups.

METHODS

Using data from the U.S. Department of Veterans Affairs (VA) Million Veteran Program (MVP), we examined the relationship between dementia risk factors (APOE ε4, PTSD, TBI) and subjective cognitive concerns (SCC) measured in individuals of European (n = 140,921), African (n = 15,788), and Hispanic (n = 8,064) ancestry (EA, AA, and HA, respectively). We then used data from the VA electronic medical record to perform a retrospective survival analysis evaluating PTSD, TBI, APOE ε4, and SCC and their associations with risk of conversion to ADRD in Veterans aged 65 and older.

RESULTS

PTSD symptoms (B = 0.50-0.52, p < 1E-250) and probable TBI (B = 0.05-0.19, p = 1.51E-07 - 0.002) were positively associated with SCC across all three ancestry groups. APOE ε4 was associated with greater SCC in EA Veterans aged 65 and older (B = 0.037, p = 1.88E-12). Results of Cox models indicated that PTSD symptoms (hazard ratio [HR] = 1.13-1.21), APOE ε4 (HR = 1.73-2.05) and SCC (HR = 1.18-1.37) were positively associated with risk for ADRD across all three ancestry groups. In the EA group, probable TBI also contributed to increased risk of ADRD (HR = 1.18).

CONCLUSIONS

The findings underscore the value of SCC as an indicator of ADRD risk in Veterans 65 and older when considered in conjunction with other influential genetic, clinical, and demographic risk factors.

Cardiology Encounters for Underrepresented Racial and Ethnic Groups with Human Immunodeficiency Virus and Borderline Cardiovascular Disease Risk

BACKGROUND

Underrepresented racial and ethnic groups (UREGs) with HIV have a higher risk of cardiovascular disease (CVD) compared with the general population. Referral to a cardiovascular specialist improves CVD risk factor management in high-risk individuals. However, patient and provider factors impacting the likelihood of UREGs with HIV to have an encounter with a cardiologist are unknown.

METHODS

We evaluated a cohort of UREGs with HIV and borderline CVD risk (10-year risk ≥ 5% by the pooled cohort equations or ≥ 7.5% by Framingham risk score). Participants received HIV-related care from 2014-2020 at four academic medical centers in the United States (U.S.). Adjusted Cox proportional hazards regression was used to estimate the association of patient and provider characteristics with time to first ambulatory cardiology encounter.

RESULTS

A total of 2,039 people with HIV (PWH) and borderline CVD risk were identified. The median age was 45 years (IQR: 36-50); 52% were female; and 94% were Black. Of these participants, 283 (14%) had an ambulatory visit with a cardiologist (17% of women vs. 11% of men, p < .001). In fully adjusted models, older age, higher body mass index (BMI), atrial fibrillation, multimorbidity, urban residence, and no recent insurance were associated with a greater likelihood of an encounter with a cardiologist.

CONCLUSION

In UREGs with HIV and borderline CVD risk, the strongest determinants of a cardiology encounter were diagnosed CVD, insurance type, and urban residence. Future research is needed to determine the extent to which these encounters impact CVD care practices and outcomes in this population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04025125.

Association Between Coronary Assessment in Heart Failure and Clinical Outcomes Within a Safety-Net Setting Using a Target Trial Emulation Observational Design

BACKGROUND

Ischemic cardiomyopathy is the leading cause of heart failure (HF). Most patients do not undergo coronary assessment after HF diagnosis. There are no randomized clinical trials of coronary assessment after HF diagnosis.

METHODS

Using an electronic health record cohort of all individuals with HF within the San Francisco Health Network from 2001 to 2019, we identified factors associated with coronary assessment. Then, we studied the association of coronary assessment within 30 days of HF diagnosis with all-cause mortality and a composite of mortality and emergent angiography using a target trial emulation observational comparative-effectiveness approach. Target trial emulation is an approach to causal inference based on creating a hypothetical randomized clinical trial protocol and using observational data to emulate the protocol. We used propensity scores for covariate adjustment. We used national death records to improve the ascertainment of mortality and included falsification end points for the cause of death.

RESULTS

Among 14 829 individuals with HF (median, 62 years old; 5855 [40%] women), 3987 (26.9%) ever completed coronary assessment, with 2467/13 301 (18.5%) with unknown coronary artery disease status at HF diagnosis assessed. Women, older individuals, and people without stable housing were less likely to complete coronary assessment. Among 5972 eligible persons of whom 627 underwent early elective coronary assessment, coronary assessment was associated with lower mortality (hazard ratio, 0.84 [95% CI, 0.72-0.97]; P=0.025), reduced risk of the composite outcome (hazard ratio, 0.86 [95% CI, 0.73-1.00]), higher rates of revascularization (odds ratio, 7.6 [95% CI, 5.4-10.6]), and higher use of medical therapy (odds ratio, 2.5 [95% CI, 1.7-3.6]), but not the falsification end points.

CONCLUSIONS

In a safety-net population, disparities in coronary assessment after HF diagnosis are not fully explained by coronary artery disease risk factors. Early coronary assessment is associated with improved HF outcomes possibly related to higher rates of revascularization and guideline-directed medical therapy but with low certainty that this finding is not attributable to unmeasured confounding.

Racial and Ethnic Disparities in Cardiac Reintervention After Pediatric Cardiac Surgical Procedures

BACKGROUND

Children undergoing cardiac surgical procedures may require postoperative surgical or catheter-based reintervention before discharge. We examined racial/ethnic variations in reintervention and associated in-hospital death.

METHODS

Children undergoing cardiac surgical procedures from 2004 to 2015 were identified in the Pediatric Health Information Systems (PHIS) database. Regression analysis measured associations between race/ethnicity, in-hospital death, and postoperative cardiac surgical or catheter-based reintervention (surgical/catheter reintervention).

RESULTS

Of 124,263 patients, 8265 (6.7%) had a surgical/catheter reintervention. Black patients had fewer reinterventions (5.9% vs 6.7%) and higher in-hospital mortality (3.9% vs 2.7%, P < .01) than White patients. After adjusting for sociodemographic and illness severity indicators, Black patients remained less likely to receive surgical/catheter reintervention (adjusted hazard ratio [aHR], 0.89; 95% CI, 0.82-0.98) despite having similar risk of death after reintervention (adjusted odds ratio, 1.17; 95% CI, 0.98-1.41) compared with White patients. The risk of death without surgical/catheter reintervention was also higher for Black (aHR, 1.26; 95% CI, 1.08-1.47) and other race/ethnicity (aHR, 1.33; 95% CI, 1.13-1.57) patients than for White patients. Similar trends were demonstrated when mechanical circulatory support and cardiac transplantation were included as reinterventions.

CONCLUSIONS

Patients of Black and other race/ethnicity undergoing pediatric cardiac surgical procedures are more likely to die without postoperative cardiac reintervention than White patients. Black patients are also less likely to receive reintervention despite no significant difference in mortality with reintervention. Further studies should evaluate etiologies and methods of addressing these disparities.

Building an ethnically and racially diverse neurology workforce

As diversity among patient populations continues to grow, racial and ethnic diversity in the neurology workforce is increasingly essential to the delivery of culturally competent care and for enabling inclusive, generalizable clinical research. Unfortunately, diversity in the workforce is an area in which the field of neurology has historically lagged and faces formidable challenges, including an inadequate number of trainees entering the field, bias experienced by trainees and faculty from minoritized racial and ethnic backgrounds, and 'diversity tax', the disproportionate burden of service work placed on minoritized people in many professions. Although neurology departments, professional organizations and relevant industry partners have come to realize the importance of diversity to the field and have taken steps to promote careers in neurology for people from minoritized backgrounds, additional steps are needed. Such steps include the continued creation of diversity leadership roles in neurology departments and organizations, the creation of robust pipeline programmes, aggressive recruitment and retention efforts, the elevation of health equity research and engagement with minoritized communities. Overall, what is needed is a shift in culture in which diversity is adopted as a core value in the field.

Deep learning in cancer genomics and histopathology

Histopathology and genomic profiling are cornerstones of precision oncology and are routinely obtained for patients with cancer. Traditionally, histopathology slides are manually reviewed by highly trained pathologists. Genomic data, on the other hand, is evaluated by engineered computational pipelines. In both applications, the advent of modern artificial intelligence methods, specifically machine learning (ML) and deep learning (DL), have opened up a fundamentally new way of extracting actionable insights from raw data, which could augment and potentially replace some aspects of traditional evaluation workflows. In this review, we summarize current and emerging applications of DL in histopathology and genomics, including basic diagnostic as well as advanced prognostic tasks. Based on a growing body of evidence, we suggest that DL could be the groundwork for a new kind of workflow in oncology and cancer research. However, we also point out that DL models can have biases and other flaws that users in healthcare and research need to know about, and we propose ways to address them.

Algorithmic Individual Fairness and Healthcare: A Scoping Review

Objective

Statistical and artificial intelligence algorithms are increasingly being developed for use in healthcare. These algorithms may reflect biases that magnify disparities in clinical care, and there is a growing need for understanding how algorithmic biases can be mitigated in pursuit of algorithmic fairness. Individual fairness in algorithms constrains algorithms to the notion that "similar individuals should be treated similarly." We conducted a scoping review on algorithmic individual fairness to understand the current state of research in the metrics and methods developed to achieve individual fairness and its applications in healthcare.

Methods

We searched three databases, PubMed, ACM Digital Library, and IEEE Xplore, for algorithmic individual fairness metrics, algorithmic bias mitigation, and healthcare applications. Our search was restricted to articles published between January 2013 and September 2023. We identified 1,886 articles through database searches and manually identified one article from which we included 30 articles in the review. Data from the selected articles were extracted, and the findings were synthesized.

Results

Based on the 30 articles in the review, we identified several themes, including philosophical underpinnings of fairness, individual fairness metrics, mitigation methods for achieving individual fairness, implications of achieving individual fairness on group fairness and vice versa, fairness metrics that combined individual fairness and group fairness, software for measuring and optimizing individual fairness, and applications of individual fairness in healthcare.

Conclusion

While there has been significant work on algorithmic individual fairness in recent years, the definition, use, and study of individual fairness remain in their infancy, especially in healthcare. Future research is needed to apply and evaluate individual fairness in healthcare comprehensively.

Implications of Patient-Provider Concordance on Treatment Recommendations for Carpal Tunnel Syndrome

Purpose

Differences in the utilization of carpal tunnel release (CTR) by Blacks and women are well documented, but less is known regarding the impact of patient-provider concordance on treatment recommendations. To investigate this, we surveyed hand surgeons using hypothetical scenarios to evaluate variations in treatment recommendations for carpal tunnel syndrome based on patient-related factors and patient-provider concordance.

Methods

Three pairs (six total) of hypothetical scenarios with clinical symptoms of carpal tunnel syndrome were created varying sex, race, and occupation. We used names as a proxy for sex and race. Occupation included manual laborers, secretaries, athletes, and retirees. American Society for Surgery of the Hand members were emailed an anonymous web-based link to participate. We used descriptive statistics to analyze the scenario-based treatment recommendations.

Results

We identified 3,067 eligible members for participation; 770 surgeons responded (25%) and provided recommendations for 3,742 scenarios. For scenarios involving symptomatic patients without electrodiagnostic studies (EDS), with normal EDS, and with abnormal EDS, no difference was noted in surgeon treatment recommendations based on patients' race, sex, and occupation. Surgeons recommended EDS for 31% and 32.8% of the scenarios with Black female and White male patients, respectively, who did not have EDS at presentation and CTR for 32.3% and 33% of White females and Black males with normal EDS, respectively. Among retired Black female and White male patients older than 80 years of age with abnormal EDS, surgeons recommended CTR in 89.9% and 89.3% of them, respectively. For patient-provider racially concordant pairs, White surgeons recommended CTR to a similar proportion of Black and White hypothetical patients; however, Black surgeons recommended CTR to a greater proportion of patients with Black-sounding names.

Conclusions

We found that surgeon treatment recommendation was not associated with patient race, sex, or occupation; however, differences did emerge based on patient-provider racial concordance, suggesting that alignment of patient and provider identities may influence treatment recommendations.

Type of study/level of evidence

Prognostic III.

Diagnostic Overshadowing of Psychological Disorders in People With Intellectual Disability: A Systematic Review

Diagnostic overshadowing is a bias in which symptoms of a psychological disorder are falsely attributed to a known diagnosis of intellectual disability. This systematic review evaluated all research on diagnostic overshadowing conducted to date, including dissertations and peer-reviewed journal articles. In total, 25 studies were included in this review. Findings suggest diagnostic overshadowing may not be as ubiquitous as originally believed, with one third of included studies finding no overshadowing. The quality of the evidence was graded as "Low" using the LEGEND tool, with common issues including outdated studies, analogue methodologies, small sample sizes and convenience samples, and inappropriate conducting or reporting of statistical analyses. Implications for the field and recommendations for future research are discussed.

Patient Characteristics Associated With Using Transcatheter Left Atrial Appendage Occlusion Versus Oral Anticoagulants for Atrial Fibrillation

BACKGROUND

Transcatheter left atrial appendage occlusion (LAAO) is an alternative to oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation, but the predictors of LAAO use in routine care are unclear. We aimed to assess the utilization trends of LAAO and compare the change in characteristics of LAAO users versus OACs since its marketing.

METHODS

Using the US Medicare claims database (March 15, 2015, to December 31, 2020), we identified patients with atrial fibrillation, ≥65 years, and CHA2DS2-VASc score ≥2 (men) or ≥3 (women), with either first implantation of an LAAO device or initiation of OACs, including apixaban, dabigatran, rivaroxaban, edoxaban, or warfarin. Patient characteristics, measured 365 days before the first LAAO or OAC use date, were compared using logistic regression.

RESULTS

There were 30 058 LAAO recipients (mean age, 77.74 years; female, 42.1%) and 792 600 OAC initiators (mean age, 78.48; female, 53.3%). In 2020, patients had higher odds of initiating LAAO use than in 2015 (0.52 versus 9.32%; adjusted odds ratio [aOR], 13.64 [95% CI, 12.56-14.81]). Old age (ie, >85 versus 65-75 years; aOR, 0.84 [95% CI, 0.80-0.88]), female sex (aOR, 0.74 [95% CI, 0.71-0.76]), Black race (aOR, 0.63 [95% CI, 0.58-0.68]) versus White race, and Medicaid eligibility (aOR, 0.61 [95% CI, 0.58-0.64]) were associated with lower odds of receiving LAAO. Among clinical characteristics, frailty, cancer, fractures, and venous thromboembolism were associated with lower odds of LAAO use, while history of intracranial and extracranial bleeding, coagulopathy, and falls were associated with higher odds of receiving LAAO.

CONCLUSIONS

Among patients with atrial fibrillation receiving stroke-preventive therapy, LAAO use increased rapidly from 2015 to 2020 and was positively associated with the risk factors for OAC complications but negatively associated with old age, advanced frailty, and cancer. Black race and female sex were associated with a lower likelihood of receiving LAAO.

Gender Bias in Diagnosis, Prevention, and Treatment of Cardiovascular Diseases: A Systematic Review

Cardiovascular disease (CVDs) has been perceived as a 'man's disease', and this impacted women's referral to CVD diagnosis and treatment. This study systematically reviewed the evidence regarding gender bias in the diagnosis, prevention, and treatment of CVDs. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. We searched CINAHL, PubMed, Medline, Web of Science, British Nursing Index, Scopus, and Google Scholar. The included studies were assessed for quality using risk bias tools. Data extracted from the included studies were exported into Statistical Product and Service Solutions (SPSS, v26; IBM SPSS Statistics for Windows, Armonk, NY), where descriptive statistics were applied. A total of 19 studies were analysed. CVDs were less reported among women who either showed milder symptoms than men or had their symptoms misdiagnosed as gastrointestinal or anxiety-related symptoms. Hence, women had their risk factors under-considered by physicians (especially by male physicians). Subsequently, women were offered fewer diagnostic tests, such as coronary angiography, ergometry, electrocardiogram (ECG), and cardiac enzymes, and were referred to less to cardiologists and/or hospitalisation. Furthermore, if hospitalised, women were less likely to receive a coronary intervention. Similarly, women were prescribed cardiovascular medicines than men, with the exception of antihypertensive and anti-anginal medicines. When it comes to the perception of CVD, women considered themselves at lower risk of CVDs than men. This systematic review showed that women were offered fewer diagnostic tests for CVDs and medicines than men and that in turn influenced their disease outcomes. This could be attributed to the inadequate knowledge regarding the differences in manifestations among both genders.

Racial and Ethnic Disparities in Perioperative Health Care Among Patients Undergoing Cardiac Surgery: JACC State-of-the-Art Review

There has been little progress in reducing health care disparities since the 2003 landmark Institute of Medicine's report Unequal Treatment. Despite the higher burden of cardiovascular disease in underrepresented racial and ethnic groups, they have less access to cardiologists and cardiothoracic surgeons, and have higher rates of morbidity and mortality with cardiac surgical interventions. This review summarizes existing literature and highlights disparities in cardiovascular perioperative health care. We propose actionable solutions utilizing multidisciplinary perspectives from cardiology, cardiac surgery, cardiothoracic anesthesiology, critical care, medical ethics, and health disparity experts. Applying a health equity lens to multipronged interventions is necessary to eliminate the disparities in perioperative health care among patients undergoing cardiac surgery.

Climate change and cancer: the Environmental Justice perspective

Despite advances in cancer control-prevention, screening, diagnosis, treatment, and survivorship-racial disparities in cancer incidence and survival persist and, in some cases, are widening in the United States. Since 2020, there's been growing recognition of the role of structural racism, including structurally racist policies and practices, as the main factor contributing to historical and contemporary disparities. Structurally racist policies and practices have been present since the genesis of the United States and are also at the root of environmental injustices, which result in disproportionately high exposure to environmental hazards among communities targeted for marginalization, increased cancer risk, disruptions in access to care, and worsening health outcomes. In addition to widening cancer disparities, environmental injustices enable the development of polluting infrastructure, which contribute to detrimental health outcomes in the entire population, and to climate change, the most pressing public health challenge of our time. In this commentary, we describe the connections between climate change and cancer through an Environmental Justice perspective (defined as the fair treatment and meaningful involvement of people of all racialized groups, nationalities, or income, in all aspects, including development, implementation, and enforcement, of policies and practices that affect the environment and public health), highlighting how the expertise developed in communities targeted for marginalization is crucial for addressing health disparities, tackling climate change, and advancing cancer control efforts for the entire population.