Reducing Racial Health Care Disparities: A Social Psychological Analysis

Assessing Bias Toward a Black or White Simulated Patient with Obesity in a Virtual Reality-Based Genomics Encounter

Interpersonal bias based on weight and race is widespread in the clinical setting; it is crucial to investigate how emerging genomics technologies will interact with and influence such biases in the future. The current study uses a virtual reality (VR) simulation to investigate the influence of apparent patient race and provision of genomic information on medical students' implicit and explicit bias toward a virtual patient with obesity. Eighty-four third- and fourth-year medical students (64% female, 42% White) were randomized to interact with a simulated virtual patient who appeared as Black versus White, and to receive genomic risk information for the patient versus a control report. We assessed biased behavior during the simulated encounter and self-reported attitudes toward the virtual patient. Medical student participants tended to express more negative attitudes toward the White virtual patient than the Black virtual patient (both of whom had obesity) when genomic information was absent from the encounter. When genomic risk information was provided, this more often mitigated bias for the White virtual patient, whereas negative attitudes and bias against the Black virtual patient either remained consistent or increased. These patterns underscore the complexity of intersectional identities in clinical settings. Provision of genomic risk information was enough of a contextual shift to alter attitudes and behavior. This research leverages VR simulation to provide an early look at how emerging genomic technologies may differentially influence bias and stereotyping in clinical encounters.

Factors Associated With Loss to Follow Up After Temporal Bone Fracture

INTRODUCTION

Inpatient and outpatient evaluation is important for management of temporal bone trauma due to the possible otologic complications that can result. However, there is limited literature on follow up rates following temporal bone fracture. This study aimed to determine the proportion of patients lost to follow up after sustaining temporal bone fractures and identify factors associated with loss to follow up.

METHODS

Retrospective review of adult patients who sustained temporal bone fractures at a level I trauma center from January 1, 2019 to January 1, 2024 was completed (IRB H-44161). The primary outcome included prevalence of patient loss to follow up. Secondary variables included initial radiographic and exam findings, otologic complications, and demographic characteristics. Patients who were seen in follow up and lost to follow up were compared, and odds of loss to follow up was calculated.

RESULTS

Sixty-nine patients met inclusion criteria for this study, of which 30 patients (43.5%) were lost to follow up. Patients who were White had a significantly lower odds of loss to follow up than those who were not White (OR = 0.2506 (95% CI: 0.0706, 0.8067, P = .0024). While need for acute management was not significantly different between the groups, a significantly lower proportion of patients who were intubated on presentation (P = .0091), had abnormal otoscopic exam (P = .0211), and had otologic complications (P = .0056) were lost to follow up.

CONCLUSION

Almost half of patients who sustained temporal bone fractures, including a significantly higher odds of minority race/ethnicity patients, were lost to follow up.

Racial Bias in Pediatric Pain Perception

Racial disparities in pediatric pain care are prevalent across a variety of health care settings, and likely contribute to broader disparities in health, morbidity, and mortality. The present research expands on prior work demonstrating potential perceptual contributions to pain care disparities in adults and tests whether racial bias in pain perception extends to child targets. We examined the perception and hypothetical treatment of pain in Black and White boys (experiment 1), Black and White boys and girls (experiment 2), Black and White boys and adult men (experiment 3), and Black, White, Asian, and Latinx boys (experiment 4). Across this work, pain was less readily perceived on Black (vs White) boys' faces-though this bias was not observed within girls. Moreover, this perceptual bias was comparable in magnitude to the same bias measured with adult targets and consistently predicted bias in hypothetical treatment. Notably, bias was not limited to Black targets-pain on Hispanic/Latinx boys' faces was also relatively underperceived. Taken together, these results offer strong evidence for racial bias in pediatric pain perception. PERSPECTIVE: This article demonstrates perceptual contributions to racial bias in pediatric pain recognition. Participants consistently saw pain less readily on Black boys' faces, compared with White boys, and this perceptual bias consistently predicted race-based gaps in treatment. This work reveals a novel factor that may support pediatric pain care disparities.

Resilience in Black Women: Lifeline or Double-Edged Sword?

Black women face many health disparities, many of which are tied to the stress of being a marginalized group member. Resilience, defined as the ability to bounce back from adversity and continue with life, has been introduced as a method to buffer the stress that Black women experience and improve their outcomes. However, there is not a universally agreed-upon definition of resilience in the literature. Thus, it is unclear how resilience works broadly, particularly for Black women. It is important to explore whether resilience is as positive as many scholars have perceived it to be. The current review analyzes 28 empirical articles that looked at stress, resilience, and health outcomes in Black women. The review revealed that there are many inconsistencies in how both stress and resilience are measured. Further, the positive effects of resilience seem to be largely context-dependent and vary depending on the demographic and health outcomes explored.

Diagnostic Errors in Obstetric Morbidity and Mortality: Methods for and Challenges in Seeking Diagnostic Excellence

Pregnancy-related morbidity and mortality remain high across the United States, with the majority of deaths being deemed preventable. Misdiagnosis and delay in diagnosis are thought to be significant contributors to preventable harm. These diagnostic errors in obstetrics are understudied. Presented here are five selected research methods to ascertain the rates of and harm associated with diagnostic errors and the pros and cons of each. These methodologies include clinicopathologic autopsy studies, retrospective chart reviews based on clinical criteria, obstetric simulations, pregnancy-related harm case reviews, and malpractice and administrative claim database research. We then present a framework for a future study of diagnostic errors and the pursuit of diagnostic excellence in obstetrics: (1) defining and capturing diagnostic errors, (2) targeting bias in diagnostic processes, (3) implementing and monitoring safety bundles, (4) leveraging electronic health record triggers for case reviews, (5) improving diagnostic skills via simulation training, and (6) publishing error rates and reduction strategies. Evaluation of the effectiveness of this framework to ascertain diagnostic error rates, as well as its impact on patient outcomes, is required.

Study protocol for transforming health equity research in integrated primary care: Antiracism as a disruptive innovation

Among the consequences of systemic racism in health care are significant health disparities among Black/African American individuals with comorbid physical and mental health conditions. Despite decades of studies acknowledging health disparities based on race, significant change has not occurred. There are shockingly few evidence-based antiracism interventions. New paradigms are needed to intervene on, and not just document, racism in health care systems. We are developing a transformative paradigm for new antiracism interventions for primary care settings that integrate mental and physical health care. The paradigm is the first of its kind to integrate community-based participatory research and systems science, within an established model of early phase translation to rigorously define new antiracism interventions. This protocol will use a novel application of systems sciences by combining the qualitative systems sciences methods (group model building; GMB) with quantitative methods (simulation modeling) to develop a comprehensive and community-engaged view of both the drivers of racism and the potential impact of antiracism interventions. Community participants from two integrated primary health care systems will engage in group GMB workshops with researchers to 1) Describe and map the complex dynamic systems driving racism in health care practices, 2) Identify leverage points for disruptive antiracism interventions, policies and practices, and 3) Review and prioritize a list of possible intervention strategies. Advisory committees will provide feedback on the design of GMB procedures, screen potential intervention components for impact, feasibility, and acceptability, and identify gaps for further exploration. Simulation models will be generated based on contextual factors and provider/patient characteristics. Using Item Response Theory, we will initiate the process of developing core measures for assessing the effectiveness of interventions at the organizational-systems and provider levels to be tested under a variety of conditions. While we focus on Black/African Americans, we hope that the resulting transformative paradigm can be applied to improve health equity among other marginalized groups.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Racial Differences in Perioperative Complications, Readmissions, and Mortalities After Elective Spine Surgery in the United States: A Systematic Review Using AI-Assisted Bibliometric Analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVES

To evaluate the impact of race on post-operative outcomes and complications following elective spine surgery in the United States.

METHODS

PUBMED, MEDLINE(R), ERIC, EMBASE, and SCOPUS were searched for studies documenting peri-operative events for White and African American (AA) patients following elective spine surgery. Pooled odds ratios were calculated for each 90-day outcome and meta-analyses were performed for 4 peri-operative events and 7 complication categories. Sub-analyses were performed for each outcome on single institution (SI) studies and works that included <100,000 patients.

RESULTS

53 studies (5,589,069 patients, 9.8% AA) were included. Eleven included >100,000 patients. AA patients had increased rates of 90-day readmission (OR 1.33, P = .0001), non-routine discharge (OR 1.71, P = .0001), and mortality (OR 1.66, P = .0003), but not re-operation (OR 1.16, P = .1354). AA patients were more likely to have wound-related complications (OR 1.47, P = .0001) or medical complications (OR 1.35, P = .0006), specifically cardiovascular (OR 1.33, P = .0126), deep vein thrombosis/pulmonary embolism (DVT/PE) (OR 2.22, P = .0188) and genitourinary events (OR 1.17, P = .0343). SI studies could only detect racial differences in re-admissions and non-routine discharges. Studies with <100,000 patients replicated the above findings but found no differences in cardiovascular complications. Disparities in mortality were only detected when all studies were included.

CONCLUSIONS

AA patients faced a greater risk of morbidity across several distinct categories of peri-operative events. SI studies can be underpowered to detect more granular complication types (genitourinary, DVT/PE). Rare events, such as mortality, require larger sample sizes to identify significant racial disparities.

Implicit racial bias among dental hygienists practicing in the United States

PURPOSE

Provider bias has been shown to be a contributing factor to racial and ethnic disparities observed in health care settings. The purpose of this study was to examine implicit racial bias among dental hygienists.

METHODS

A convenience sample of licensed and practicing dental hygienists within the United States was recruited through email and national dental hygiene social media groups via snowball sampling. A two-part survey design was used for data collection. Participants completed a 10-item demographic survey through an online platform and were then routed to the Race Implicit Association Test (IAT). Descriptive statistics and linear regression analyses were used to compare demographic data and implicit racial preference scores (d-scores).

RESULTS

Data from 404 licensed dental hygienists were included in this study. Over two-thirds (67.8%) of participants showed a preference for European Americans over African Americans. A significant difference was found between implicit racial preference scores and participant age (Estimate: 0.01, 95% CI: 0.00, 0.01), years worked comparing <5 years to 21 or more years (Estimate: 0.19, 95% CI: -0.30, -0.09) and race comparing non-White to White (Estimate: -0.17, 95% CI: -0.27, -0.07). No difference was found with task order, previous Race IAT experience, or previous self-reported implicit bias training.

CONCLUSIONS

Findings suggest that dental hygienists may harbor implicit racial preferences for European Americans over African Americans. Non-White participants had more positive implicit preferences toward African Americans compared to White participants. Further research is needed to determine the extent to which implicit racial biases contribute to disparities in oral health.

Shared Decision-Making and Patient Communication in Nephrology Practice

Shared decision-making (SDM) is the standard of care for patient or surrogates and their clinicians to arrive at a medical decision. Evidence suggests that SDM increases patients' understanding of their illness and satisfaction with their decision-making process. Dialysis patients often report the perception that they were passive participants in the decision to start dialysis, suggesting further opportunities for enhancing the application of SDM in decision-making with patients with kidney disease. The hallmark feature of SDM is sensitive, culturally- and equity-informed communication and effective partnership between patient or surrogate and clinician. In the process, the patient's personal expertise in the realm of their values and priorities is elicited, and the clinician's medical expertise is shared. The integration of this shared expertise then leads to an informed treatment decision. Frameworks such as the Serious Illness Conversation Guide and REMAP are guides for the SDM process, and communication tools and mnemonics can help facilitate SDM conversations. This paper will address SDM in nephrology practice, reviewing underlying supportive evidence, context, and timing for employing SDM in the trajectory of chronic kidney disease and acute kidney injury, special considerations in vulnerable populations to promote health equity, and communication tools and frameworks to facilitate the SDM process. By learning and applying these frameworks and tools, nephrology providers will be able to employ SDM in the management of kidney disease.

Do Hospital Characteristics Predict Racial-and-Ethnic Disparities in Patient Experience? National Results From the HCAHPS Survey

OBJECTIVE

Assess whether hospital characteristics associated with better patient experiences overall are also associated with smaller racial-and-ethnic disparities in inpatient experience.

BACKGROUND

Hospitals that are smaller, non-profit, and serve high proportions of White patients tend to be high-performing overall, but it is not known whether these hospitals also have smaller racial-and-ethnic disparities in care.

RESEARCH DESIGN

We used linear mixed-effect regression models to predict a summary measure that averaged eight Hospital CAHPS (HCAHPS) measures (Nurse Communication, Doctor Communication, Staff Responsiveness, Communication about Medicines, Discharge Information, Care Coordination, Hospital Cleanliness, and Quietness) from patient race-and-ethnicity, hospital characteristics (size, ownership, racial-and-ethnic patient-mix), and interactions of race-and-ethnicity with hospital characteristics.

SUBJECTS

Inpatients discharged from 4,365 hospitals in 2021 who completed an HCAHPS survey ( N =2,288,862).

RESULTS

While hospitals serving larger proportions of Black and Hispanic patients scored lower on all measures, racial-and-ethnic disparities were generally smaller for Black and Hispanic patients who received care from hospitals serving higher proportions of patients in their racial-and-ethnic group. Experiences overall were better in smaller and non-profit hospitals, but racial-and-ethnic differences were slightly larger.

CONCLUSIONS

Large, for-profit hospitals and hospitals serving higher proportions of Black and Hispanic patients tend to be lower performing overall but have smaller disparities in patient experience. High-performing hospitals might look at low-performing hospitals for how to provide less disparate care whereas low-performing hospitals may look to high-performing hospitals for how to improve patient experience overall.

Socioeconomic differences in antibiotic use for common infections in pediatric urgent-care centers-A quasi-experimental study

OBJECTIVE

To investigate differences in the rate of firstline antibiotic prescribing for common pediatric infections in relation to different socioeconomic statuses and the impact of an antimicrobial stewardship program (ASP) in pediatric urgent-care clinics (PUCs).

DESIGN

Quasi-experimental.

SETTING

Three PUCs within a Midwestern pediatric academic center.

PATIENTS AND PARTICIPANTS

Patients aged >60 days and <18 years with acute otitis media, group A streptococcal pharyngitis, community-acquired pneumonia, urinary tract infection, or skin and soft-tissue infections who received systemic antibiotics between July 2017 and December 2020. We excluded patients who were transferred, admitted, or had a concomitant diagnosis requiring systemic antibiotics.

INTERVENTION

We used national guidelines to determine the appropriateness of antibiotic choice in 2 periods: prior to (July 2017-July 2018) and following ASP implementation (August 2018-December 2020). We used multivariable regression analysis to determine the odds ratios of appropriate firstline agent by age, sex, race and ethnicity, language, and insurance type.

RESULTS

The study included 34,603 encounters. Prior to ASP implementation in August 2018, female patients, Black non-Hispanic children, those >2 years of age, and those who self-paid had higher odds of receiving recommended firstline antibiotics for all diagnoses compared to male patients, children of other races and ethnicities, other ages, and other insurance types, respectively. Although improvements in prescribing occurred after implementation of our ASP, the difference within the socioeconomic subsets persisted.

CONCLUSIONS

We observed socioeconomic differences in firstline antibiotic prescribing for common pediatric infections in the PUCs setting despite implementation of an ASP. Antimicrobial stewardship leaders should consider drivers of these differences when developing improvement initiatives.

Association of racial discrimination in health care settings and use of electronic cigarettes to quit smoking among Black adults

INTRODUCTION

Black people are disproportionately burdened by tobacco-related diseases and are less successful at cigarette cessation with current treatments. We know little about the effectiveness of e-cigarettes as a smoking cessation method compared to currently approved methods in Black adults who smoke. Many Black adults report experiencing racial discrimination in health care, but if discrimination is related to utilization of smoking cessation aids including e-cigarettes and success with smoking cessation in this population is unclear. Therefore, this exploratory study aimed to understand how negative experiences and racial discrimination in health care influence use of e-cigarettes for cigarette cessation and success with cigarette cessation among Black adults.

METHODS

The study interviewed 201 Black adults who used cigarettes and tried to quit in their lifetime from the Family and Community Health Study in 2016. The study asked if they had tried and successfully quit cigarettes with e-cigarettes vs. other methods (support groups, medications, nicotine replacement therapies, call-in help lines, cold turkey [quit on their own], counseling) and asked about their negative experiences and racial discrimination in health care. We performed separate logistic regressions that evaluated the association of negative experiences and racial discrimination in health care with 1) use of e-cigarettes for cigarette cessation vs. other quitting methods and 2) success with cigarette cessation using any method among Black adults while controlling for age, sex, socioeconomic status, health insurance status, and age of onset of cigarette use.

RESULTS

More reported negative experiences and racial discrimination in health care were associated with ever trying to quit with e-cigarettes compared to other methods (OR:1.75, 95 % CI [1.05-2.91]), but negative experiences and racial discrimination in health care were not associated with cigarette quitting success. Interestingly, trying e-cigarettes was associated with being less successful at quitting compared to using other methods to quit smoking (OR: 0.40, 95 % CI [0.20, 0.81]).

CONCLUSIONS

These results suggest that educating health care professionals that anticipated discrimination in health care settings may be driving Black adults who smoke to engage in non-evidence-based smoking cessation practices, such as e-cigarettes instead of those that are evidence-based, and may be more effective in this population.

Balancing evidence-based care with patient-centered individualized care

Weak evidence, when manifested in clinical guidelines, can translate into biased vascular care. In vascular surgery, we have few randomized controlled trials with appropriate representation of females and persons of color, so generalizability of trial results can be problematic. Physicians are required to balance evidenced-based care (which is only as good as the underlying evidence) with personalized treatment recommendations that are often based on demographics, social circumstances, and/or existing therapeutic relationships. Biases, whether implicit or explicit, have an oversized effect on treatment decisions, and patient outcomes. In this commentary, we propose three principles to strengthen the vascular surgery evidence foundation and patient-centered decision-making going forward: (1) generating evidence designed for individualized care, (2) constructing clinical guidelines that are context specific and complexity aware, and (3) strengthening the training and support for surgeons to deliver patient-centered individualized care.

The Diagnosis of Malingering in General Hospitals in the United States: A Retrospective Analysis of the National Inpatient Sample

Objective

To characterize the socio-demographics and comorbid medical and psychiatric diagnoses of patients in the general hospital diagnosed with malingering.

Method

We conducted a retrospective observational cohort study using data from the 2019 National Inpatient Sample, an all-payors database of acute care general hospital discharges in the United States, querying for patients aged 18 and older discharged with a diagnosis of "malingerer [conscious simulation]," ICD-10 code Z76.5.

Results

45,645 hospitalizations (95% CI: 43,503 to 47,787) during the study year included a discharge diagnosis of malingering. 56.1% were for male patients, and the median age was 43 years (IQR 33 to 54). Black patients represented 26.8% of the patients with a discharge diagnosis of malingering, compared to 14.9% of all patients sampled. Zip codes in the lowest household income quartile comprised 39.9% of malingering diagnoses. The top categories of primary discharge diagnoses of hospitalizations included medical ("Diabetes mellitus without complications"), psychiatric ("Depressive disorders"), and substance use ("Alcohol-related disorders") disorders. "Sepsis, unspecified organism," was the most common primary diagnosis.

Conclusion

The striking overrepresentation of Black patients in hospitalizations with diagnosis of malingering raises concern about the roles of implicit and systemic biases in assigning this label. The disproportionate number of patients of low socioeconomic status is further suggestive of bias and disparity. Another potential contribution is that the lower health literacy in these populations results in a limited knowledge of traditional ways to meet one's needs and thus greater reliance on malingered behavior as an alternative means. Accurate description of these patients' socio-demographics and comorbid medical and psychiatric diagnoses with reliable data from large samples can lead to improved understanding of how the malingering label is applied and ultimately better patient care.

Race, economic status, and disparities in the receipt of benzodiazepine prescriptions in a large primary care sample

OBJECTIVE

To evaluate the relationship between race, economic status, and patient characteristics with benzodiazepine prescribing in an urban and suburban primary care context.

METHOD

This retrospective study used data from a previously described cohort of patients seen in a large Ohio healthcare system's primary care clinics from 2019 to 2020. Associations and interactions between race, economic status (using median income of patient ZIP code as a proxy), patient characteristics, and prescription of benzodiazepines were assessed using multivariable logistic regression.

RESULTS

455,537 patients had 1,643,473 primary care visits, and 5.8% of patients were prescribed a benzodiazepine. White patients were prescribed benzodiazepines more often than Multiracial/Multicultural, African American and Asian American patients (6.5%, 3.8%, 2.7% and 2.0% respectively). Patients from lower income ZIP codes were less likely to receive a prescription. Interaction effects were observed between race, patient economic status, gender, insurance status, and diagnoses (general anxiety disorder, insomnia, and panic disorder). The largest prescribing disparities by race were among patients with these three diagnoses. The largest disparity in prescription by income was seen in African American patients.

CONCLUSION

African American, Multicultural/Multiracial and Asian American patients were less likely than White patients to receive benzodiazepine prescriptions. Middle and lower-income patients are particularly susceptible to this prescribing disparity.

Systemic Racism's Impact on Minority Children and Youth With Psychosis: Enacting Antiracist Strategies in Psychosis Care

Psychotic disorders represent a treatable but debilitating subset of mental illnesses. Children and adolescents who are given a diagnosis of psychosis are at risk for serious sequelae that may affect cognitive and social function. Alarmingly, evidence has shown that racial differences exist in the diagnosis and progression of pathology. This article presents a conceptualization of the challenges that minority pediatric patients diagnosed with a psychotic disorder often confront, and explores practical means to antiracist care.

Acceptability of a Serious Illness Conversation Guide to Black Americans: Results from a focus group and oncology pilot study

OBJECTIVES

Serious illness conversations (SICs) can improve the experience and well-being of patients with advanced cancer. A structured Serious Illness Conversation Guide (SICG) has been shown to improve oncology patient outcomes but was developed and tested in a predominantly White population. To help address disparities in advanced cancer care, we aimed to assess the acceptability of the SICG among African Americans with advanced cancer and their clinicians.

METHODS

A two-phase study conducted in Charleston, SC, included focus groups to gather perspectives on the SICG in Black Americans and a single-arm pilot study of a revised SICG with surveys and qualitative exit interviews to evaluate patient and clinician perspectives. We used descriptive analysis of survey results and thematic analysis of qualitative data.

RESULTS

Community-based and patient focus group participants (N = 20) reported that a simulated conversation using an adapted SICG built connection, promoted control, and fostered consideration of religious faith and family. Black patients with advanced cancer (N = 23) reported that SICG-guided conversations were acceptable, helpful, and promoted conversations with loved ones. Oncologists found conversations feasible to implement and skill-building, and also identified opportunities for training and implementation that could support meeting the needs of their patients with low health literacy. An adapted SICG includes language to assess the strength and affirm the clinician-patient relationship.

SIGNIFICANCE OF RESULTS

An adapted structured communication tool to facilitate SIC, the SICG, appears acceptable to Black Americans with advanced cancer and seems feasible for use by oncology clinicians working with this population. Further testing in other marginalized populations may address disparities in advanced cancer care.

The Impact of Language on the Mental Health of Black Quebecers

Quebec's English-speaking Black community finds itself at the intersection of racial and linguistic discrimination, which presents challenges to mental wellness. The present study aims to add necessary detail to the conversations surrounding racism and mental health in Canada while including language as a determinant of health and intersecting element affecting the wellbeing of English-speaking Black Quebecers. We recruited 531 Black adults who are currently living in Quebec to complete a survey on various community-relevant items, including their mental and physical health, their experiences of discrimination, and barriers to accessing mental healthcare. Our analyses revealed that English-speaking participants experience more discrimination across all types and report more barriers to mental healthcare and lower mental health than their French-speaking counterparts. Furthermore, we found that language also had a mediated effect on mental health through discrimination and barriers to mental healthcare. Our study adds to the sparse race-based and intersectional literature about Black people in Canada and substantiates a mechanism by which language affects mental health by exposing Black Quebecers to more discrimination and thus higher barriers to care.

Disparities in Healthcare Accessibility and Discrimination Faced by Black Quebecers: a Race and Language Perspective

The Black population in Canada is characterized by its long-established history and diversity. The present study aims to expand our current understanding of the relation between discrimination and disparities in healthcare by including race and language as determinants of health. We recruited 531 Black adults who are currently living in Quebec, Canada, to complete a survey measuring socio-demographic characteristics, mental and physical health, accessibility to healthcare, and experiences of discrimination. Results showed that being a racialized and linguistic minority population in Quebec, English-speaking Black participants experienced more discrimination, fewer healthcare providers, less access to COVID-19 information during the COVID-19 pandemic, and were more dissatisfied with the healthcare system than French-speaking Black participants. Furthermore, the negative impacts of healthcare access associated with being a racialized and linguistic minority population in Quebec (e.g., the English-speaking Black population) were shown to be mediated by experiences of discrimination and dissatisfaction with the healthcare system.

Investigating the Association of Pain Intensity and Health Status among Older US Adults with Pain Who Used Opioids in 2020 Using the Medical Expenditure Panel Survey

The number of older United States (US) adults is increasing, yet extra life years are not always spent in good health. This study explored the relationship between pain intensity and health status among US adults aged ≥50 with pain who used an opioid in the 2020 Medical Expenditure Panel Survey using multivariable logistic regression adjusting for demographic, economic, and health variables. Most (60.2%) older US adult opioid users with pain reported having good health (versus 39.8% poor health). In the fully adjusted analysis, those with extreme pain (odds ratio (OR) = 0.19, 95% confidence interval (CI) = 0.10, 0.35) and quite a bit of pain (OR = 0.34, 95% CI = 0.19, 0.60) had lower odds of reporting good health compared to those with little pain. There was no statistical relationship between health status for moderate versus little pain. In addition, males (versus females; OR = 0.61, 95% CI = 0.40, 0.91), white race (versus not white; OR = 0.43, 95% CI = 0.22, 0.84), education ≤high school (versus >high school; OR = 0.61, 95% CI = 0.41, 0.92), and current smoker (versus non-smoker; OR = 0.55, 95% CI = 0.32, 0.93) were associated with lower odds of reporting good health. Being employed (versus unemployed; OR = 1.88, 95% CI = 1.06, 3.33), having <2 chronic conditions (versus ≥2; OR = 4.38, 95% CI = 1.91, 10.02), and doing regular physical activity (versus not; OR = 2.69, 95% CI = 1.73, 4.19) were associated with higher odds of reporting good health. These variables should be considered when assessing the health needs and developing treatment plans for older US adult opioid users with pain.

The Patient and Carer Race Equality Framework: a model to reduce mental health inequity in England and Wales

The Patient and Carer Race Equality Framework (PCREF) is an Organisational Competence Framework (OCF), recommended by the Independent Review of the Mental Health Act as a means to improve mental health access, experience and outcomes for people from ethnic minority backgrounds, particularly Black people. This is a practical framework that should be co-produced with and tailored to the needs of service users, based on quality improvement and place-based approaches. We aim to use the PCREF to address the longstanding epistemic justices experienced by people with mental health problems, particularly those from minoritised ethnic groups. We will outline the work that led to the proposal, the research on racial inequalities in mental health in the UK, and how the PCREF will build on previous interventions to address these. By taking these into account, the PCREF should support a high minimum standard of mental health care for all.

Shared decision making with black patients: A scoping review

OBJECTIVE

The purpose of this review is to explore the breadth of research conducted on SDM in the care of Black patients.

METHODS

We conducted a scoping review following the methodological framework outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. We searched articles related to original research on SDM in the care of Black patients in October 2022 using PubMed, Embase, and Google Scholar databases. Articles of all study designs (quantitative and qualitative), published or translated into English, were included. A standardized data extraction form and thematic analysis were used to facilitate data extraction by two independent reviewers.

RESULTS

After removal of duplicates and screening, 30 articles were included in the final analysis. Black patients and clinician were found to not share the same understanding of SDM, and patients highly valued SDM in their care. Interventions to improve SDM yielded mixed results to enhance intent, participation in SDM, as well as health outcomes. Decision aids were the most effective form of intervention to enhance SDM. The most common barrier to SDM was patient-clinician communication, and was exacerbated by racial discordance, clinician mistrust, past experiences, and paternalistic clinician-patient dynamics.

CONCLUSIONS

SDM has the potential to improve health outcomes in Black patients when implemented contextually within Black patients' experiences and concerns. Significant barriers such as clinician mistrust exist, and the overall perception in the Black community is that SDM does not occur sufficiently. Barriers to SDM seem to be most pronounced when there is patient-clinician racial discordance. Several interventions aimed at improving SDM with Black patients have shown mixed results. Future studies should evaluate larger-scale interventions with longer follow-up. Practice implications Shared decision making (SDM) has been proposed as a useful tool for improving quality and equity in Black patients' care. However, Black patients experience lower rates of SDM compared to other populations. SDM has the potential to improve health outcomes in Black patients when implemented contextually within Black patients' experiences and concerns.

Disparate Utilization of Breast Conservation Therapy in the Surgical Management of Early-Stage Breast Cancer

BACKGROUND

Despite evidence suggesting oncologic equipoise of breast conservation therapy (BCT) for early-stage (stages I and II) breast cancer, mastectomy is still widely utilized.

PATIENTS AND METHODS

The 2004-2015 National Cancer Database was used to tabulate all adult women receiving mastectomy or BCT for early-stage breast cancer. Multivariable regression was used to evaluate factors associated with utilization of BCT, relative to mastectomy.

RESULTS

Of 1,079,057 women meeting study criteria, 57.4% underwent BCT. BCT patients were older and more commonly White, compared to mastectomy. They were more commonly privately insured, in the highest income quartile, and treated at metropolitan, nonacademic institutions. After adjustment, increasing age (AOR 1.01/year), Black race (AOR 1.21, Ref: White), and care at a community hospital (AOR 1.08, Ref: Academic; all P< .05) were associated with increased odds of undergoing BCT. Conversely, Asian or Pacific Islander (AAPI) race (AOR 0.74), Medicare (AOR 0.89) or Medicaid (AOR 0.95) coverage, and being in the lowest (AOR 0.95) and second lowest (AOR 0.98, all P< .05) income quartiles were associated with reduced odds of undergoing BCT. Finally, increasing tumor size (AOR 0.97, P< .05) was associated with decreased adjusted odds of undergoing BCT.

CONCLUSION

Our results suggest persistent socioeconomic and racial disparities in BCT utilization for early-stage breast cancer. Directed strategies should be implemented in order to reduce treatment inequality in this patient population.

Disparities in Elective and Nonelective Total Hip Arthroplasty

BACKGROUND

Prior studies have shown disparities in utilization of primary and revision total hip arthroplasty (THA). However, little is known about patient population differences associated with elective and nonelective surgery. Therefore, the aim of this study was to explore factors that influence primary utilization and revision risk of THA based on surgery indication.

METHODS

Data were obtained from 7,543 patients who had a primary THA from 2014 to 2020 in a database, which consists of multiple health partner systems in Louisiana and Texas. Of these patients, 602 patients (8%) underwent nonelective THA. THA was classified as "elective" or "nonelective" if the patient had a diagnosis of hip osteoarthritis or femoral neck fracture, respectively.

RESULTS

After multivariable logistic regression, nonelective THA was associated with alcohol dependence, lower body mass index (BMI), women, and increased age and number of comorbid conditions. No racial or ethnic differences were observed for the utilization of primary THA. Of the 262 patients who underwent revision surgery, patients who underwent THA for nonelective etiologies had an increased odds of revision within 3 years of primary THA (odds ratio (OR) = 1.66, 95% Confidence Interval (CI) = 1.06-2.58, P-value = .025). After multivariable logistic regression, patients who had tobacco usage (adjusted odds ratio (aOR) = 1.36, 95% CI = 1.04-1.78, P-value = .024), alcohol dependence (aOR = 2.46, 95% CI = 1.45-4.15, P-value = .001), and public insurance (OR = 2.08, 95% CI = 1.18-3.70, P-value = .026) had an increased risk of reoperation.

CONCLUSION

Demographic and social factors impact the utilization of elective and nonelective primary THA and subsequent revision surgery. Orthopaedic surgeons should focus on preoperative counseling for tobacco and alcohol cessation as these are modifiable risk factors to directly decrease reoperation risk.

Responsive social support serves important functions in clinical communication: Translating perspectives from relationship science to improve cancer clinical interactions

Patient-clinician interactions are critical to patient-centered care, including in cancer care contexts which are often defined by multiple patient-clinician interactions over an extended period. Research on these dyadic interactions has been guided by perspectives in clinical communication science, but the study of clinical communication has not been fully integrated with perspectives on interpersonal interactions from relationship science research. An overlapping concept in both fields is the concept of responsive socialsupport. In this article, we discuss responsiveness as a concept that offers opportunities for connections between these two disciplines. Next, we focus on how relationship science can be applied to research in clinical settings. We discuss how three areas of relationship science define responsiveness and have potential for extension to clinical communication: (1) (in)visibility of social support, (2) attachment orientations, and (3) shared meaning systems. We also discuss how social biases can impede responsiveness and suggest research avenues to develop ideas and understand potential challenges in connecting these two fields. Many opportunities exist for interdisciplinary theory development that can generate momentum in understanding interpersonal processes in cancer care.

Racism and Quality of Neonatal Intensive Care: Voices of Black Mothers

BACKGROUND AND OBJECTIVES

Black preterm infants are more likely to die than White preterm infants within the same NICU. Racism may lead to disparate quality of NICU care contributing to disparities in preterm infant health outcomes. The objective of our study was to understand Black mothers' perspectives of the impact of racism on the quality of care for Black preterm infants in the NICU and what might be done to address it.

METHODS

Using qualitative research methods, we conducted in-depth, semistructured interviews with 20 Black mothers of preterm infants in a single Level IV NICU 6 to 18 months after hospital discharge regarding experiences with disparate quality of NICU care. We developed themes iteratively and conducted interviews until thematic saturation was reached.

RESULTS

The majority of mothers believed that racism impacted the quality of NICU care and described examples of racism in the NICU at structural, institutional, and interpersonal levels. Mothers also provided ideas for interventions that would decrease racism and improve quality of NICU care for Black families, including increased Black representation, increased peer support, and improved staff education and training.

CONCLUSIONS

Black mothers of preterm infants experienced racism during NICU hospitalization that impacted the quality of care they received. Interventional studies directed toward mitigating these racial disparities may focus on addressing racism during the NICU period and should include input from Black stakeholders at all stages of design, implementation, and analysis.

African American Women's Maternal Healthcare Experiences: A Critical Race Theory Perspective

Black women are experiencing pregnancy-related complications at a significantly higher rate than women of other races in the U.S., as Black women are three to four times likely to die from pregnancy-related complications compared to non-Hispanic White women. Structural barriers and different forms of marginalization continue to limit Black women's access to quality healthcare services. Through critical race theory, we examine what structural barriers exist in the U.S. healthcare system, one that limits access to quality care during their prenatal and postnatal doctor's visits. Using qualitative in-depth interviews, 31 African American women, living in Milwaukee, WI, shared their pregnancy stories. The emergent themes include, institutionalized care - racially insensitive biomedical approach, race and class - unfair treatment based on health insurance, and race as a social concept - dismissed pain concerns because you are a strong Black woman. These themes reveal the experience of racial discrimination toward African American women through healthcare [communicative] practices that are often times seen as "standard" practices, albeit marginalizing minority populations. Findings from this study offer insights for healthcare providers on communicative practices that foster a racially-safe healthcare environment for African American women.

Non-White Race/Ethnicity and Female Sex Are Associated with Increased Allogeneic Red Blood Cell Transfusion in Cardiac Surgery Patients: 2007-2018

OBJECTIVE

To evaluate racial and/or ethnic and sex disparities in allogeneic and autologous red blood cell (RBC) transfusions in cardiac surgery.

DESIGN

A retrospective observational study.

SETTING

2007 to 2018 data from FL, MD, KY, WA, NY, and CA from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality.

PARTICIPANTS

A total of 710,296 inpatients who underwent elective or emergency coronary artery bypass grafting (CABG), cardiac valve surgery,or combination CABG and/or valve surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were cohorted by race and/or ethnicity and sex, as defined by SID-HCUP. Demographic characteristics and comorbidities were compared. Rates and risk-adjusted odds ratios (aOR) were calculated for allogeneic and autologous RBC transfusion (primary outcomes). Additional secondary analyses were conducted for in-hospital mortality, 30-day readmission, 90-day readmission, hospital length of stay, and total charges to examine the effect of RBC transfusion status. Effect modification between race and sex was assessed. When controlling for patient demographics, comorbidities, and hospital characteristics, non-White patients were more likely to receive an allogeneic RBC transfusion during cardiac surgery than White patients (Black: aOR 1.17, 99% CI 1.13-1.20, p < 0.001, Hispanic: aOR 1.22, 99% CI 1.19-1.22, p < 0.001). Women were more likely to receive allogeneic RBC than men (aOR 1.69, 99% CI 1.66-1.72, p < 0.001). In interaction models, non-White women had the highest odds of allogeneic blood transfusion as compared to White men (reference category; Black women: aOR 2.04, 99% CI 1.91-2.17, p < 0.001, Hispanic women: aOR 2.03, 99% CI 1.90-2.16, p < 0.001).

CONCLUSION

These findings highlighted the differences in the rates of allogeneic RBC transfusion for non-White and female patients undergoing cardiac surgery, which is a well-established marker of poorer outcomes.

The role of stereotypical information on medical judgements for black and white patients

THIS ARTICLE USES WORDS OR LANGUAGE THAT IS CONSIDERED PROFANE, VULGAR, OR OFFENSIVE BY SOME READERS. The new generation of direct-acting antivirals has improved dramatically the rates of cure for chronic hepatitis C. Yet, evidence shows that racial groups are deemed more often ineligible for hepatitis C treatment, despite no clinical evidence supporting differential treatment for Black and White patients. One possible explanation has to do with providers’ racial biases. This investigation sought to explore medical students’ racial stereotypes (Study 1, N = 171) and the role of stereotypical cues on perceptions of medical adherence of Black and White patients (Study 2, N = 208). In Study 1, we first sought to identify health-related aspects that are consistently associated with Blacks as part of a stereotype. In Study 2, we experimentally manipulated racial stereotypes identified in Study 1 by asking participants to read a clinical vignette depicting a patient (Black vs. White) and their medical history (cause of exposure to hepatitis C: unprotected sex vs. non-injectable drugs use). The results show that the impact of stereotypicality on patient perceived compliance varies as a function of medical students’ racial prejudice. Implications for further applied health inequalities research and for medical training are discussed.

Society for Maternal-Fetal Medicine Special Statement: Cognitive bias and medical error in obstetrics-challenges and opportunities

The processes of diagnosis and management involve clinical decision-making. However, decision-making is often affected by cognitive biases that can lead to medical errors. This statement presents a framework of clinical thinking and decision-making and shows how these processes can be bias-prone. We review examples of cognitive bias in obstetrics and introduce debiasing tools and strategies. When an adverse event or near miss is reviewed, the concept of a cognitive autopsy-a root cause analysis of medical decision-making and the potential influence of cognitive biases-is promoted as part of the review process. Finally, areas for future research on cognitive bias in obstetrics are suggested.

Racial Disparities in Renal Outcomes over Time among Hospitalized Children with Systemic Lupus Erythematosus

OBJECTIVES

Racial and ethnic minority groups have excess morbidity related to renal disease in pediatric-onset systemic lupus erythematosus (SLE). We evaluated temporal trends in renal outcomes and racial disparities among hospitalized children with SLE over 14 years.

METHODS

We identified patients ≤21 years-old with discharge diagnoses of SLE in the Pediatric Health Information System® inpatient database (2006-2019). Adverse renal outcomes included end-stage renal disease (ESRD), dialysis, or transplant, analyzed as a composite and separately. We estimated the odds of adverse renal outcomes at any hospitalization, or the first occurrence of an adverse renal outcome, adjusted for calendar period, patient characteristics, and clustering by hospital. We tested whether racial disparities differed by calendar period.

RESULTS

There were 20,893 admissions for 7,434 SLE patients, of which 32%, 16%, 12% and 8% were Black, Hispanic White, Hispanic Other and Asian, respectively. Proportions of admissions with adverse renal outcomes decreased over time (p<0.01). Black children remained at highest risk of adverse renal outcomes at any admission (OR 2.5, 95% CI [1.8-3.5] vs. non-Hispanic White). Black and Asian children remained at higher risk of incident adverse renal outcomes, driven by ESRD among Black children (OR 1.6 [1.2-2.1]) and dialysis among Asians (OR 1.7 [1.1-2.7]). Relative disparities did not change significantly over time.

CONCLUSION

Significant reductions in ESRD and dialysis occurred over time for children with SLE across all racial and ethnic groups. The lack of corresponding reductions in racial disparities highlights the need for targeted interventions to achieve greater treatment benefit among higher risk groups.

Metacognitive Beliefs about Uncontrollability Relate Most Strongly to Health Anxiety among U.S.-based non-Latinx White Primary Care Patients: Comparing Strength of Relations with U.S.-based non-Latinx Black and Latinx Primary Care Patients

Metacognitive beliefs have emerged as important to health anxiety, particularly beliefs that health-related thoughts are uncontrollable. Preliminary research examining generalized worry indicates uncontrollability beliefs relate more strongly to anxiety among U.S.-based self-identifying White relative to Black college students. The present study sought to extend that line of research by examining if metacognitive beliefs about the uncontrollability of health-related thoughts differentially relate to health anxiety among self-identifying non-Latinx Black (n = 123), Latinx (n = 104), and non-Latinx White (n = 80) U.S.-based primary care patients. As predicted, although positive associations were seen across all three groups, beliefs that health-related thoughts are uncontrollable more strongly related to health anxiety among White patients compared to both Black and Latinx patients. Those differential relations held in multivariate analyses while statistically controlling for positive depression screening status, generalized anxiety symptom severity, and medical morbidity. Although the effect size surrounding the differential relations was small in magnitude, the present results further support the notion that metacognitive beliefs about uncontrollability relate less strongly to anxiety among U.S.-based ethnoracial minorities compared to White individuals. Potential reasons for the differential relations are discussed, along with additional areas for future research.

Association of Health-Care System and Survival in African American and Non-Hispanic White Patients With Bladder Cancer

BACKGROUND

African American patients with bladder cancer have inferior outcomes compared with non-Hispanic White (White) patients. We hypothesize that access to health care is a primary determinant of this disparity. We compared outcomes by race for patients with bladder cancer receiving care within the predominant hybrid-payer health-care model of the United States captured in the Surveillance, Epidemiology, and End Results (SEER) database with those receiving care within the equal-access model of the Veterans' Health Administration (VHA).

METHODS

African American and White patients diagnosed with bladder cancer were identified in SEER and VHA. Stage at presentation, bladder cancer-specific mortality (BCM), and overall survival (OS) were compared by race within each health-care system.

RESULTS

The SEER cohort included 122 449 patients (93.7% White, 6.3% African American). The VHA cohort included 36 322 patients (91.0% White, 9.0% African American). In both cohorts, African American patients were more likely to present with muscle-invasive disease and metastases, but the differences between races were statistically significantly smaller in VHA. In SEER multivariable models, African American patients had worse BCM (hazard ratio [HR] = 1.22, 95% confidence interval [CI] = 1.15 to 1.29) and OS (HR = 1.26, 95% CI = 1.20 to 1.31). In contrast within the VHA, African American patients had similar BCM (HR = 0.97, 95% CI = 0.88 to 1.07) and OS (HR = 0.99, 95% CI = 0.93 to 1.05).

CONCLUSIONS

In this study of contrasting health-care models, receiving medical care in an equal-access system was associated with reduced differences in stage at presentation and eliminated disparities in survival outcomes for African American patients with bladder cancer. Our findings highlight the importance of reducing financial barriers to care to notably improve health equity and oncologic outcomes for African American patients.

Acute Ischemic Stroke Interventions in the United States and Racial, Socioeconomic, and Geographic Disparities

BACKGROUND AND OBJECTIVES

In patients with ischemic stroke (IS), IV alteplase (tissue plasminogen activator [tPA]) and endovascular thrombectomy (EVT) reduce long-term disability, but their utilization has not been fully optimized. Prior research has also demonstrated disparities in the use of tPA and EVT specific to sex, race/ethnicity, socioeconomic status, and geographic location. We sought to determine the utilization of tPA and EVT in the United States from 2016-2018 and if disparities in utilization persist.

METHODS

This is a retrospective, longitudinal analysis of the 2016-2018 National Inpatient Sample. We included adult patients who had a primary discharge diagnosis of IS. The primary study outcomes were the proportions who received tPA or EVT. We fit a multivariate logistic regression model to our outcomes in the full cohort and also in the subset of patients who had an available baseline National Institutes of Health Stroke Scale (NIHSS) score.

RESULTS

The full cohort after weighting included 1,439,295 patients with IS. The proportion who received tPA increased from 8.8% in 2016 to 10.2% in 2018 (p < 0.001) and who had EVT from 2.8% in 2016 to 4.9% in 2018 (p < 0.001). Comparing Black to White patients, the odds ratio (OR) of receiving tPA was 0.82 (95% confidence interval [CI] 0.79-0.86) and for having EVT was 0.75 (95% CI 0.70-0.81). Comparing patients with a median income in their zip code of ≤$37,999 to >$64,000, the OR of receiving tPA was 0.81 (95% CI 0.78-0.85) and for having EVT was 0.84 (95% CI 0.77-0.91). Comparing patients living in a rural area to a large metro area, the OR of receiving tPA was 0.48 (95% CI 0.44-0.52) and for having EVT was 0.92 (95% CI 0.81-1.05). These associations were largely maintained after adjustment for NIHSS, although the effect size changed for many of them. Contrary to prior reports with older datasets, sex was not consistently associated with tPA or EVT.

DISCUSSION

Utilization of tPA and EVT for IS in the United States increased from 2016 to 2018. There are racial, socioeconomic, and geographic disparities in the accessibility of tPA and EVT for patients with IS, with important public health implications that require further study.

Cultural issues on accessing mental health services in Nepali and Iranian migrants communities in the UK

Mental health in Black Asian and Minority Ethnic (BAME) communities is a rising public health concern in the UK, with key challenges around accessing mental health services. Our understanding of mental health issues in the growing Nepali and Iranian communities in the UK is very limited. Therefore, this study aims to explore the major factors affecting access to, and engagement with NHS mental health services. This study used a qualitative approach comprising in-depth interviews with seven Nepali, eight Iranians and six community mental health workers in the south of England. The data were analysed using a thematic approach. Six themes were identified: (1) stigma and fear; (2) gender; (3) language; (4) tradition and culture; (5) family involvement; and (6) lack of cultural awareness in health workers, all appearing to be major issues. This study contributes to a shared understanding of mental illness within two given cultural contexts to promote early interventions in UK mental health services. Developing cross-cultural perspectives in health care should be a priority in practice.

The contribution of racism-related stress and adversity to disparities in birth outcomes: evidence and research recommendations

Currently, racial and ethnic differences in adverse birth outcomes and infant mortality are some of the largest and most persistent health disparities in the United States. This narrative review article synthesizes existing literature to present a conceptual model of how racism-related stress and adversity are critical determinants of such disparities. We describe how historical and ongoing racism has created conditions wherein women of color are disproportionately exposed to chronic, multilayered stress and adversity and how the biological consequences of exposure to these stressors confers risk for adverse birth outcomes. Next, we identify important priorities and considerations for future research, including the heterogeneity of racism-related stressors, biomarkers and mechanisms, chronicity and sensitive periods of exposure, developmental programming of lifespan health, resilience, and community-engaged research methodologies.

•

Historical and ongoing racism has created conditions wherein women of color are disproportionately exposed to stress and adversity.

•

The consequences of exposure to racism-related stress and adversity can confer risk for health conditions implicated in adverse birth outcomes and alter maternal physiology associated with fetal development and timing of parturition.

•

Conjointly studying racism-related stress, biologic profiles, and birth outcomes is a priority for future research.

•

It is important to identify factors that mitigate the impact of racism-related stress and adversity on birth outcomes.

Racial Disparities in Outcomes After Spine Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

Racial disparities are a major issue in health care but the overall extent of the issue in spinal surgery outcomes is unclear. We conducted a systematic review/meta-analysis of disparities in outcomes among patients belonging to different racial groups who had undergone surgery for degenerative spine disease.

METHODS

We searched Ovid MEDLINE, Scopus, Cochrane Review Database, and ClinicalTrials.gov from inception to January 20, 2021 for relevant articles assessing outcomes after spine surgery stratified by race. We included studies that compared outcomes after spine surgery for degenerative disease among different racial groups.

RESULTS

We found 30 studies that met our inclusion criteria (28 articles and 2 published abstracts). We included data from 20 cohort studies in our meta-analysis (3,501,830 patients), which were assessed to have a high risk of observation/selection bias. Black patients had a 55% higher risk of dying after spine surgery compared with white patients (relative risk [RR], 1.55, 95% confidence interval [CI], 1.28-1.87; I² = 70%). Similarly, black patients had a longer length of stay (mean difference, 0.93 days; 95% CI, 0.75-1.10; I² = 73%), and higher risk of nonhome discharge (RR, 1.63; 95% CI, 1.47-1.81; I² = 89%), and 30-day readmission (RR, 1.45; 95% CI, 1.03-2.04; I² = 96%). No significant difference was noted in the pooled analyses for complication or reoperation rates.

CONCLUSIONS

Black patients have a significantly higher risk of unfavorable outcomes after spine surgery compared with white patients. Further work in understanding the reasons for these disparities will help develop strategies to narrow the gap among the racial groups.

'First Do No Harm': physician discretion, racial disparities and opioid treatment agreements

The increasing use of opioid treatment agreements (OTAs) has prompted debate within the medical community about ethical challenges with respect to their implementation. The focus of debate is usually on the efficacy of OTAs at reducing opioid misuse, how OTAs may undermine trust between physicians and patients and the potential coercive nature of requiring patients to sign such agreements as a condition for receiving pain care. An important consideration missing from these conversations is the potential for racial bias in the current way that OTAs are incorporated into clinical practice and in the amount of physician discretion that current opioid guidelines support. While the use of OTAs has become mandatory in some states for certain classes of patients, physicians are still afforded great leeway in how these OTAs are implemented in clinical practice and how their terms should be enforced. This paper uses the guidelines provided for OTA implementation by the states of Indiana and Pennsylvania as case studies in order to argue that giving physicians certain kinds of discretion may exacerbate racial health disparities. This problem cannot simply be addressed by minimising physician discretion in general, but rather by providing mechanisms to hold physicians accountable for how they treat patients on long-term opioid therapy to ensure that such treatment is equitable.

Perceptions of free will and self-control in a medically relevant treatment recommendation scenario

Do provider perceptions of patient free will and treatment related self-control influence treatment recommendations and do such perceptions differ due to race? If so, such bias may be a mechanism for racial disparities in medical treatment recommendations. We hypothesized: (1) greater perceived patient free will would indirectly effect treatment recommendations for patients through increased perceived patient treatment related self-control; (2) participants would perceive greater free will for a hypothetical racial ingroup patient than outgroup patient; and (3) such effect would be exacerbated by greater levels of racial identity and racial bias. A 2 (Participant: Black vs. White) x 2 (Target: Black vs. White) x Continuous (Racial Identity/Racial Bias) between-subjects design supported hypothesis 1. Perceived patient free will predicted more rigorous treatment recommendations treatment related self-control. No evidence was found in support of hypotheses 2 and 3. Using a novel experimental design, this work demonstrates the importance of free will and self-control perceptions.

Power and Efficacy of Maternal Voice in Neonatal Intensive Care Units: Implicit Bias and Family-Centered Care

INTRODUCTION

Implicit bias can lead medical professionals in Neonatal Intensive Care Units (NICUs) to disregard mothers who are Black and economically disadvantaged as they advocate for their infants' health. Disregard can weaken underlying communication principles within the Family-Centered Care (FCC) model of pediatric health in NICUs and increase maternal distress. This study is the first to address communication disregard by examining mothers' perceived power and efficacy of voice with NICU doctors and nurses. We hypothesized that mothers who are Black and economically disadvantaged would report lower efficacy of voice and higher levels of distress as compared to White mothers with higher income.

METHODS

During pre-assessment within a small clinical trial of a parenting intervention, 33 racially and economically diverse mothers, from three Midwest NICUs serving the urban poor, responded to a 14-item measure of maternal power and efficacy of voice and measures of somatization, depression, anxiety and eating/sleeping disorders. Nonparametric examinations assessed the relation of power and efficacy of voice to maternal race, income, and distress.

RESULTS

In contrast to White, higher-income mothers, Black, economically disadvantaged mothers reported lower perceived efficacy of voice with doctors (U = 74.5, d = 0.65) and nurses (U = 74.0; d = .0.66). These mothers with lower perceived efficacy with doctors and nurses, reported higher levels of somatization (U = 16.5, d = 1.14; U = 13.5, d = 1.38, respectively) and eating disorders (U = 14.0, d = 1.29; U = 12.0, d = 1.48, respectively).

DISCUSSION

Study results are discussed within the framework of implicit bias in FCC in the NICU, expanding our understanding of effective communication with economically stressed, Black mothers.

Reducing HPV Associated Cancers and Disparities: Engaging African American Men to Develop a Culturally-Appropriate Program that Addresses their Needs

Background

The Healthy Men, Health Communities program aims to improve preventive behaviors among African American men to reduce HPV-related cancer disparities.

Purpose

We describe the development of an educational intervention using cultural-targeting strategies (i.e., linguistics, peripherals, evidence, socio-culture, and constituent-involving).

Methods

After building capacity of community-based organization (CBO) leaders as research team members, we conducted 3 focus groups, 30 surveys, and a community review and program evaluation with African American men.

Results

Focus group themes were: 1) The Known and Unknown of Cancer, HPV, and the vaccine; (2) Personal experiences with cancer were commonplace; (3) Barriers to Engaging HPV Cancer Preventive Behaviors; (4) Multi-Modal Strategies are needed to improve preventive behaviors; and (5) Actual versus Preferred Sources of Information. Survey data indicated men desired information on penile (52%) and oral cancers (48%). The preferred education format was a summit with speakers on various topics (96%). Post-summit evaluation indicated majority of males intended to get screened (73%), eat healthier (77%), and exercise more (64%). About 40% reported getting themselves, children, or grandchildren the HPV vaccine.

Discussion

Our program demonstrated acceptability, feasibility, and preliminary efficacy. This work warrants further study as a potential program to improve HPV preventive behaviors among African American men.

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

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

A look at racial and socioeconomic disparities in post-mastectomy breast reconstruction at a midwestern academic hospital

Purpose of this study was to assess likelihood of undergoing breast reconstruction based on race, socioeconomic status, insurance, and distance from the hospital. Patients with public insurance were less likely to undergo reconstruction than patients with private insurance (OR = 2.99, p < 0.001). White patients were more likely to undergo reconstruction (OR = 0.62, p = 0.02). Patients who lived 10-20 miles and 20-40 miles from UCMC were more likely to undergo reconstruction (OR = 1.93, p = 0.01; OR = 3.06, p < 0.001). White patients and patients with private insurance are disproportionately undergoing breast reconstruction after mastectomy.

Racial/Ethnic Differences in Staff-Assessed Pain Behaviors Among Newly Admitted Nursing Home Residents

CONTEXT

Nonverbal pain behaviors are effective indicators of pain among persons who have difficulty communicating. In nursing homes, racial/ethnic differences in self-reported pain and pain management have been documented.

OBJECTIVES

We sought to examine racial/ethnic differences in nonverbal pain behaviors and pain management among residents with staff-assessed pain.

METHODS

We used the U.S. national Minimum Data Set 3.0 and identified 994,510 newly admitted nursing home residents for whom staff evaluated pain behaviors and pain treatments between 2010 and 2016. Adjusted prevalence ratios (aPRs) and 95% CIs estimated using robust Poisson models compared pain behaviors and treatments across racial/ethnic groups.

RESULTS

Vocal complaints were most commonly recorded (18.3% non-Hispanic black residents, 19.3% of Hispanic residents, and 30.3% of non-Hispanic white residents). Documentation of pain behaviors was less frequent among non-Hispanic black and Hispanic residents than non-Hispanic white residents (e.g., vocal complaints: aPR_Black: 0.76; 95% CI: 0.73-0.78; with similar estimates for other pain behaviors). Non-Hispanic blacks (47.3%) and Hispanics (48.6%) were less likely to receive any type of pharmacologic pain intervention compared with non-Hispanic white residents (59.3%) (aPR_Black: 0.87; 95% CI: 0.86-0.88; aPR_Hispanics: 0.87; 95% CI: 0.84-0.89).

CONCLUSION

Among residents requiring staff assessment of pain because they are unable to self-report, nursing home staff documented pain and its treatment less often in Non-Hispanic blacks and Hispanics than in non-Hispanic white residents. Studies to understand the role of differences in expression of pain, explicit bias, and implicit bias are needed to inform interventions to reduce disparities in pain documentation and treatment.

Disentangling the Coronavirus Disease 2019 Health Disparities in African Americans: Biological, Environmental, and Social Factors

The stark racial disparities related to the coronavirus disease 2019 (COVID-19) pandemic in the United States, wherein minority populations are disproportionately getting infected and succumbing to the disease, is of grave concern. It is critical to understand and address the underlying causes of these disparities that are complex and driven by interacting environmental, social and biological factors. In this article we focus on the African American community and examine how social and environmental determinants of health intersect with biological factors (comorbidities, underlying genetics, host immunity, vitamin D levels, epigenetics) to exacerbate risk for morbidity and mortality.

Becoming an Antiracist Neonatal Community

BACKGROUND

There are pervasive and documented disparities in maternal and infant outcomes related to race and ethnicity. Critical awareness is growing in our current cultural environment about strategies to improve health equity, the need to challenge implicit bias, and dismantle racism in healthcare to decrease racial health inequities.

METHODS

In this article, we provide a summary of health inequities that exist within the perinatal/neonatal population and offer strategies for initiating conversations and improving health equity by challenging bias and increasing diversity.

RESULTS

Transformative leaders must understand the evidence related to health disparities, understand social drivers of inequity issues, and identify solutions to influence change.

IMPLICATIONS FOR PRACTICE

With heightened awareness and examination of implicit bias, we can improve care for all infants and their families.

IMPLICATIONS FOR RESEARCH

We need to continue research and quality improvement efforts to improve health equity. Furthermore, research is needed that focus on social determinants of health as drivers of preterm delivery and birth complications, rather than biological (eg, racialized) factors.Video Abstract available at:https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=42.