Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review

Addressing racial disparities in cancer care: A collaborative grant initiative

A competitive grants program developed by the American Cancer Society and Pfizer Global Medical Grants funded 10 quality improvement projects aimed at reducing systemic barriers and addressing cancer disparities for Black men and women. This introduction details the purpose and scope of this program and addresses the potential for similar projects addressing disparities along the cancer care continuum.

County-level racial bias is associated with worse care for white and especially black older US adults: a cross-sectional observational study

OBJECTIVE

To assess the association of county-level bias about black and white people with patient experience, influenza immunisation, and quality of clinical care for black and white older US adults (age 65+ years).

DESIGN

Linear multivariable regression measured the cross-sectional association of county-level estimates of implicit and explicit bias about black and white people with patient experiences, influenza immunisation, and clinical quality-of-care for black and white older US adults.

PARTICIPANTS

We used data from 1.9 million white adults who completed implicit and explicit bias measures during 2003-2018, patient experience and influenza immunisation data from respondents to the 2009-2017 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Surveys, and clinical quality-of-care data from patients whose records were included in 2009-2017 Healthcare Effectiveness Data and Information Set (HEDIS) submissions (n=0.8-2.9 million per measure).

MAIN OUTCOME MEASURES

Three patient experience measures and patient-reported influenza immunisation from the MCAHPS Survey; five HEDIS measures.

RESULTS

In county-level models, higher pro-white implicit bias was associated with lower immunisation rates and worse scores for some patient experience measures for black and white adults as well as larger-magnitude black-white disparities. Higher pro-white implicit bias was associated with worse scores for some HEDIS measures for black and white adults but not with black-white disparities in clinical quality of care. Most significant associations were small in magnitude (effect sizes of 0.2-0.3 or less).

CONCLUSIONS

To the extent that county-level pro-white implicit bias is indicative of bias among healthcare providers, there may be a need for interventions designed to prevent such bias from adversely affecting the experiences and preventive care of black patients and the clinical quality of care for all patients.

Individual child factors affecting the diagnosis of attention deficit hyperactivity disorder (ADHD) in children and adolescents: a systematic review

Attention deficit hyperactivity disorder (ADHD) is a prevalent condition characterised by patterns of inattention, hyperactivity, and impulsivity. This systematic literature review aims to identify the child clinical and sociodemographic factors related to the detection and diagnosis of ADHD in children and adolescents, given concerns about delays or failures in identifying ADHD as well as over-diagnosis, hindering appropriate and timely support for children and families. Through electronic and manual searches of peer-reviewed and grey literature, 5852 articles were identified and subjected to two stages of screening by independent reviewers. Due to the heterogeneity in study methods, a narrative approach was used to summarise study findings. Forty-one studies meeting eligibility criteria revealed sixteen child-related factors influencing the ADHD diagnostic process. These factors include ADHD subtype, ADHD symptom severity, comorbid mental disorders, behavior problems, internalizing symptoms, functional impairment, social and cognitive functioning, physical health, gender, age, relative age, race/ethnicity, socio-economic status, insurance coverage, residence urbanicity, and family structure. While the impact of many of these factors on ADHD diagnosis was inconsistent due to the substantial diversity in study designs and context, certain patterns emerged. Meeting the criteria for the inattentive subtype, lower functional impairment, female gender, Black or Latinx ethnicity, and being relatively young for their grade were consistently found to be associated with a delayed or absent ADHD diagnosis. Further research is needed to explore the intricate relationships between these child-level variables and their implications for ADHD recognition, referral, and evaluation, especially outside the USA.

Does Mindfulness Improve Intergroup Bias, Internalized Bias, and Anti-Bias Outcomes?: A Meta-Analysis of the Evidence and Agenda for Future Research

Whereas mindfulness has been shown to enhance personal well-being, studies suggest it may also benefit intergroup dynamics. Using an integrative conceptual model, this meta-analysis examined associations between mindfulness and (a) different manifestations of bias (implicit/explicit attitudes, affect, behavior) directed toward (b) different bias targets (outgroup or ingroup, e.g., internalized bias), by (c) intergroup orientation (toward bias or anti-bias). Of 70 samples, 42 (N = 3,229) assessed mindfulness-based interventions (MBIs) and 30 (N = 6,002) were correlational studies. Results showed a medium-sized negative effect of MBIs on bias outcomes, g = -0.56, 95% confidence interval [-0.72, -0.40]; I(2;3)2: 0.39; 0.48, and a small-to-medium negative effect between mindfulness and bias for correlational studies, r = -0.17 [-0.27, -0.03]; I(2;3)2: 0.11; 0.83. Effects were comparable for intergroup bias and internalized bias. We conclude by identifying gaps in the evidence base to guide future research.

Implicit Race Bias in Pediatric Patients: Understanding Patient Perspectives

INTRODUCTION

Implicit racial bias has been well studied in adults, including among orthopaedic surgeons, through the Implicit Association Test (IAT). Recent studies suggest implicit race bias is also present among children. Explicit racial preference has been studied in children through The Clark Doll Test since the 1930s. The purpose of this study was to determine whether implicit and explicit racial biases are present among pediatric orthopaedic patients.

METHODS

A prospective, cross-sectional survey was administered to pediatric orthopaedic patients aged 7 to 18 years at clinics in a tertiary pediatric hospital setting. The survey included a Clark Doll Test to determine whether pediatric patients expressed explicit bias, followed by a race IAT to determine whether pediatric patients expressed implicit bias. Preference and magnitude of implicit bias as demonstrated on the IAT was calculated using standard D-scores.

RESULTS

A total of 96 patients were consented and included in this study. Overall, pediatric patients demonstrated a slight pro-White implicit bias (M = 0.22) on IAT testing. Pediatric patients who identified as White or European American and Hispanic or Latinx both had the strongest pro-White implicit bias (M = 0.35). Patients who identified as Black or African American demonstrated no implicit racial bias (M = -0.13) on IAT testing. No notable explicit bias was observed in participants of any racial background.

DISCUSSION

This study contributes evidence that pediatric orthopaedic patients express implicit racial bias on IAT testing, with an overall slight pro-White bias. It also provides insight into the dissociation of implicit and explicit racial bias in childhood and adolescence.

CONCLUSION

We encourage future research on implicit bias among pediatric patients in the orthopaedic community to provide a better understanding and possible solutions to bias-related challenges in health care.

The Relationship Between Provider and Patient Racial Concordance and Receipt of Postpartum Care

Access to postpartum care (PPC) varies in the US and little data exists about whether patient factors may influence receipt of care. Our study aimed to assess the effect of provider-patient racial concordance on Black patients' receipt of PPC. We conducted a cross-sectional study analyzing over 24,000 electronic health records of childbirth hospitalizations at a large academic medical center  in Alabama from January 2014 to March 2020. The primary outcome variable was whether a Black patient with a childbirth hospitalization had any type of PPC visit within 12 weeks after childbirth. We used a generalized estimating equation (GEE) logistic regression model to assess the relationship between provider-patient racial concordance and receipt of PPC. Black patients with Black main providers of prenatal or childbirth care had significantly higher adjusted odds of receiving PPC (adj. OR 2.26, 95% CI 1.65-3.09, p < .001) compared to Black patients with non-Black providers. White patients who had White providers did not have statistically significantly different odds of receiving PPC compared to those with non-White providers after adjustment (adj. OR 0.88, 95% CI 0.68-1.14). Although these results should be interpreted with caution given the low number of Black providers in this sample, our findings suggest that in one hospital system in Alabama, Black birthing people with a racially concordant main prenatal and delivery care provider may have an increased likelihood of getting critical PPC follow-up.

Justice, Equity, Diversity, and Inclusion-Related Curricular Elements in Entry-Level Physical Therapist Education: A Delphi Study

INTRODUCTION

The purpose of this Delphi study was to determine whether experts in justice, equity, diversity, and inclusion (JEDI) in the field of physical therapy could achieve consensus on the key JEDI-related curricular content topics to be included in entry-level physical therapist education.

REVIEW OF LITERATURE

Inequities exist at all levels of health care for historically underserved populations, including referrals, access, and quality of physical therapy services. The physical therapy field is facing challenges and opportunities in how to best prepare providers to address individual, community, and population health inequities. There is a lack of consensus in physical therapist education regarding essential curricular content related to justice, equity, diversity, inclusion, and antiracism.

SUBJECTS

Eighty-four experts in JEDI in the physical therapy profession were invited through email to participate in the Delphi process.

METHODS

A Delphi survey brought together 39 identified experts in justice, equity, diversity, and inclusion within the field of physical therapy to reach consensus on key JEDI-related curricular topics in physical therapist education. In the first-round survey, participants answered an open-ended question: "What JEDI-related curricular content should be included in entry-level physical therapist education?" The work team coded these free-text responses to populate an initial list of curricular elements. Over 2 subsequent rounds of surveys, the experts came to a consensus on which curricular elements should be addressed within physical therapist education. Nineteen experts completed all survey rounds.

RESULTS

In round I, coding of the expert group's responses generated 61 initial JEDI-related curricular elements. By round III, the group refined the list to 43 curricular elements; 41 of the 43 (95%) elements garnered 94% or higher consensus. The expert group deemed 30 of the elements "entry-level" content and 13 as more "advanced practice" topics.

DISCUSSION AND CONCLUSIONS

Experts had a strong consensus on key JEDI-related curricular elements that physical therapist education programs should include to best prepare providers to improve the health of society. Future scholarship will explore recommendations for how physical therapist education programs might prioritize and implement JEDI-related content.

Prevalence of Medical Mistrust and Its Impact on Patient Satisfaction in Pediatric Caregivers

Racial minorities report lower perceived quality of care received compared to non-Hispanic White Americans, resulting in racial disparities in patient satisfaction. Medical mistrust, defined as a lack of confidence in the medical establishment and the intentions of medical personnel, is more prevalent among racial minority groups and is associated with poorer health outcomes. This study examines the prevalence and racial differences of patient/caregiver medical mistrust and its relationship to patient satisfaction among the pediatric patient population at a large urban academic medical center. A cross-sectional anonymous survey was conducted for caregivers of pediatric families seen at an urban tertiary care facility, including demographic information, the Patient Satisfaction Questionnaire (PSQ), and the Group-Based Medical Mistrust Scale (GBMMS). Linear regressions and mediation analyses were performed, examining race-based medical mistrust and associations with patient satisfaction. Sixty-seven surveys (67% Black/African American, 24% White) were completed. Black/African American participants reported higher levels of medical mistrust (M = 2.29, SD = 0.88 vs. M = 1.37, SD = 0.50; p < .001), which was associated with lower patient satisfaction (p < .001). In a parallel mediation analysis, disaggregating the GBMMS into three subscales, a significant indirect relationship emerged between race and patient satisfaction via the subscale lack of support from healthcare providers (95% CI [- 1.52, - .02], p < .05). Black/African American participants were more likely to have medical mistrust, and greater medical mistrust was significantly associated with lower patient satisfaction. Black/African American participants were significantly more likely to perceive lower support from healthcare providers which, in turn, was associated with lower patient satisfaction. These findings identify potential areas for intervention to improve Black/African American patients' experience with healthcare.

Addressing Bias in the Occupational Therapy Admissions Process

This study investigated the impact of a workshop in reducing unconscious bias in admissions committee members of an occupational therapy program to determine if workshop participation increased the number of underrepresented students in the program. A convenience sample of 50 committee members was used. A Wilcoxon matched pairs signed rank test indicated a significant increase in the post-test survey question scores. A chi-square test of independence revealed a significant increase in the number of students in the program from underrepresented groups. These results suggest that an online workshop can reduce perceived bias and increase diversity in an occupational therapy program.

What's in your social determinants of health teaching toolbox? Nursing pedagogical considerations

Although the concept of Social Determinants of Health (SDOH) has been around for more than two decades, teaching methods and standards of curricula for nursing education related to SDOH are relatively new concepts. Here, we explore pedagogical frameworks, national standards, and recent progress in the study and implementation of SDOH curricula and the top teaching strategies implemented in various nursing and healthcare disciplines and across educational levels (undergraduate and graduate programs). Selected examples are used to illustrate lessons learned across disciplines in effective teaching strategies related to SDOH. Effective teaching strategies include experiential learning, longitudinal and community-based interactions, reflective opportunities, and structured assessment.

The Role of Social Determinants of Health in Atherosclerotic Cardiovascular Disease

PURPOSE OF REVIEW

This review seeks to provide important information on each of the major domains of social determinants of health (SDOH) in the context of atherosclerotic cardiovascular disease.

RECENT FINDINGS

SDOH can be classified into five domains: social and community context, health care access and quality, neighborhood and built environment, economic stability, and education access and quality. SDOH are major drivers for cardiovascular health outcomes that exceed the impact from traditional risk factors, and explain inequities in health outcomes observed across different groups of individuals. SDOH profoundly impacts healthcare's receipt, delivery, and outcomes. Many patients fall within various disenfranchised groups (e.g., identify with minority race, low socioeconomic status, low educational attainment, LGBTQ+), which impact overall health status and care. Learning to understand, recognize, and address SDOH as the driving force of disparities are critical for achieving health equity in the prevention and adequate treatment of ASCVD.

Where are the Black men in osteopathic medical schools?

Over the past decade, the American Association of Colleges of Osteopathic Medicine (AACOM) and the Association of American Medical Colleges (AAMC) have emphasized the need to enhance diversity within medical education. Despite concerted efforts, the representation of underrepresented populations in medicine (URiM), particularly Black men, remains alarmingly low. This commentary delves into the persisting challenges and potential solutions surrounding the lack of diversity of Black men in osteopathic schools. Black men, in particular, continue to be significantly underrepresented in osteopathic medical schools across the United States. Factors contributing to this disparity include limited access to resources, pervasive negative stereotypes, and biases within the medical community. Addressing these challenges necessitates multifaceted interventions such as mentorship programs, pipeline initiatives, and implicit bias training to enhance the recruitment and support for URiM applicants, particularly Black men. Institutions like Touro College of Osteopathic Medicine and A.T. Still University have underscored the importance of tailoring programs in fostering a sense of belonging and academic success among Black men aspiring to be osteopathic physicians. The creation of a supportive environment for Black men in osteopathic medical schools is not only crucial for promoting diversity but also crucial for improving patient health outcomes, because research consistently depicts enhanced patient outcomes and experiences with diverse healthcare teams. However, despite progress in some areas, Black men continue to face systemic barriers and biases that hinder the pursuit of a career in osteopathic medicine. Thus, increasing the representation of Black men in osteopathic medical schools requires a concerted effort from all stakeholders, including medical institutions, policymakers, and the broader medical community. By implementing targeted interventions, fostering a sense of belonging, and addressing systemic barriers, the medical community can work toward a more equitable and inclusive future in healthcare. Ultimately, promoting diversity is not only a matter of fairness but also essential for ensuring the delivery of high-quality, culturally competent care to all patients.

Clinical Reasoning Skills Among Second-Phase Medical Students in West Bengal, India: An Exploratory Study

Introduction Proper application of clinical reasoning skills is essential to reduce diagnostic and management errors. Explicit inclusion of training and assessment of clinical reasoning skills is the demand of time. The study intended to measure the clinical reasoning skills of second-phase undergraduate students in a medical college in West Bengal, India, and its distribution across several individual variables. Methods The clinical reasoning skills of 105 undergraduate medical students were assessed in a cross-sectional exploratory study using key feature questions (KFQs) with the partial credit scoring system. Six case vignettes aligned to the core competencies in the subject of pharmacology, pathology, and microbiology were designed and validated by the subject material experts for this purpose. The responses of the participants were collected through Google Forms (Google, Mountain View, CA) after obtaining written informed consent. The scores obtained in all KFQs were added and expressed in percentage of the maximum attainable score. Results The mean (±SD) clinical reasoning score of the participants was 42.5 (±12.6). Only 29.6% of respondents scored ≥ 50. Students with higher subjective economic status (p-value = 0.01) and perceived autonomy (p-value < 0.001) were more likely to have higher clinical reasoning scores. The marks obtained in previous summative examinations were significantly correlated with clinical reasoning scores. Conclusion Average score < 50.0 and inability to score ≥ 50.0 by more than two-thirds of the participants reflected the deficit in the clinical reasoning skills of second-phase MBBS students. The association of clinical reasoning skills with economic status, autonomy, and previous academic performances needs further exploration.

Mental Health Crisis Responses and (In)Justice: Intrasystem and Intersystem Implications

Mental health crises among people who are marginalized merit special consideration. These groups are both overserved and underserved by mental health crisis systems: over-represented in acute treatment settings by number while facing inequities in outcomes. The predisposing, precipitating, and perpetuating factors that contribute to crises, however, neither begin nor end with the mental health system. Rather, these factors are multisystemic. As an illustration of this concept, this article highlights select marginalized groups, those that have faced inequities in mental health diagnosis and treatment due to race, medical complexity, age, and criminal justice system involvement.

Factors Influencing Antihypertensive Medication Adherence Among Historically Underrepresented Adults: A Meta-analysis

BACKGROUND

Addressing disparities in blood pressure control must include supporting antihypertensive medication adherence (MA). Developing effective MA interventions requires identifying the most important factors influencing MA.

OBJECTIVE

In this review, the authors aimed to meta-analyze the results of research testing associations between factors potentially influencing antihypertensive MA and assessed antihypertensive MA in historically underrepresented populations. Additional exploratory analyses focused on system-level factors, which have been understudied and may particularly impact disparities in MA.

METHODS

A health sciences librarian assisted with searching across 10 databases. Inclusion criteria included (1) published in English, (2) sample of adults with hypertension, (3) ≥50% of participants having self-identified as a race/ethnicity underrepresented in the country where the study was conducted, and (4) reporting sufficient data to calculate effect size(s).

RESULTS

Fifty-eight studies were eligible for inclusion. Nine factors met criteria for planned analyses. Older age ( r = 0.08, P < .01; k = 26 studies) and higher income ( r = 0.11, P = .01; k = 15) were significantly correlated with better MA. Having depressive symptoms was significantly correlated with worse MA ( r = -0.18, P < .01; k = 11). Effect sizes for sex, education level, marital status, number of medications, comorbidities, and perceived social support were not significant. System-level factors examined included insurance coverage, access to healthcare, perceived barriers, having a primary care provider, perceptions of their healthcare provider, and experiences of discrimination in healthcare.

CONCLUSIONS

Understanding the impact of factors associated with antihypertensive MA in historically underrepresented adults can support development of targeted, culturally relevant MA interventions. Future research should examine the impact of system-level factors on antihypertensive MA among historically underrepresented populations.

Increase in Hypofractionated Radiation Therapy Among Patients with Invasive Breast Cancer or Ductal Carcinoma In Situ: Who is Left Behind?

PURPOSE

We aimed to update the trend of hypofractionated whole-breast irradiation (HF-WBI) use over time in the US and examine factors associated with lack of HF-WBI adoption for patients with early-stage invasive breast cancer (IBC) or ductal carcinoma in situ (DCIS) undergoing a lumpectomy.

METHODS AND MATERIALS

Among patients who underwent a lumpectomy, we identified 928,034 patients with early-stage IBC and 330,964 patients with DCIS in the 2004 to 2020 National Cancer Database. We defined HF-WBI as 2.5-3.33 Gy/fraction to the breast and conventionally fractionated WBI as 1.8-2.0 Gy/fraction. We evaluated the trend of HF-WBI utilization using a generalized linear model with the log link and binomial distribution. Factors associated with HF-WBI utilization were assessed using multivariable logistic regression in patients diagnosed between 2018 and 2020.

RESULTS

Among patients with IBC, HF-WBI use has significantly increased from 0.7% in 2004 to 63.9% in 2020. Similarly, HF-WBI usage among patients with DCIS has also increased significantly from 0.4% in 2004 to 56.6% in 2020. Black patients with IBC were less likely than White patients to receive HF-WBI (adjusted odds ratio [AOR] 0.81; 95% CI, 0.77-0.85). Community cancer programs were less likely to administer HF-WBI to patients with IBC (AOR, 0.80; 95% CI, 0.77-0.84) and to those with DCIS (AOR, 0.87; 95% CI, 0.79-0.96) than academic/research programs. Younger age, positive nodes, larger tumor size, low volume programs, and facility location were also associated with lack of HF-WBI adoption in both patient cohorts.

CONCLUSIONS

HF-WBI utilization among postlumpectomy patients has significantly increased from 2004 to 2020 and can finally be considered standard of care in the US. We found substantial disparities in adoption within patient and facility subgroups. Reducing disparities in HF-WBI adoption has the potential to further alleviate health care costs while improving patients' quality of life.

Disparities in end-of-life care for minoritized racial and ethnic patients during terminal hospitalizations in New York State

BACKGROUND

Racial and ethnic minorities often receive care at different hospitals than non-Hispanic white patients, but how hospital characteristics influence the occurrence of disparities at the end of life is unknown. The aim of this study was to determine if disparities in end-of-life care were present among minoritized patients during terminal hospitalizations, and if these disparities varied with hospital characteristics.

METHODS

We identified hospitalizations where a patient died in New York State, 2016-2018. Using multilevel logistic regression, we examined whether documented end-of-life care (do-not-resuscitate status (DNR), palliative care (PC) encounter) differed by race and ethnicity, and whether these disparities differed based on receiving care in hospitals with varying characteristics (Black or Hispanic-serving hospital; teaching status; bed size; and availability of specialty palliative care).

RESULTS

We identified 143,713 terminal hospitalizations in 188 hospitals. Across all hospitals, only Black patients were less likely to have a PC encounter (adjusted odds ratio (aOR) 0.83 [0.80-0.87]) or DNR status (aOR 0.91 [0.87-0.95]) when compared with non-Hispanic White patients, while Hispanic patients were more likely to have DNR status (aOR 1.07 [1.01-1.13]). In non-teaching hospitals, all minoritized groups had decreased odds of PC (aOR 0.80 [0.76-0.85] for Black, aOR 0.91 [0.85-0.98] for Hispanic, aOR 0.93 [0.88-0.98] for Others), while in teaching hospitals, only Black patients had a decreased likelihood of a PC encounter (aOR 0.88 [0.82-0.93]). Also, Black patients in a Black-serving hospitals were less likely to have DNR status (aOR 0.80 [0.73-0.87]). Disparities did not differ based on whether specialty PC was available (p = 0.27 for PC encounter, p = 0.59 for DNR status).

CONCLUSION

During terminal hospitalizations, Black patients were less likely than non-Hispanic White patients to have documented end-of-life care. This disparity appears to be more pronounced in non-teaching hospitals than in teaching hospitals.

A Report of Salaries of Academic Cardiothoracic Surgeons Based on Race and Ethnicity

BACKGROUND

Diversity in the physician workforce improves patient care, physician well-being, and innovation. Workforce diversity is dependent on fair compensation that is unbiased by race or ethnicity. The purpose of this study was to determine whether a disparity of representation and salary on the basis of race or ethnicity exists in academic cardiothoracic surgery.

METHODS

Study investigators performed a cross-sectional analysis of data collected by the Accreditation Council of Graduate Medical Education (ACGME) and the Association of American Medical Colleges (AAMC) faculty data for US medical school faculty 2021 and 2022. Salary data were not available if an academic rank and race or ethnicity had fewer than 6 cardiothoracic surgeons. Study investigators performed a descriptive analysis of the number of faculty and compared median and mean salaries according to academic rank using a paired t test.

RESULTS

Of the 758 academic cardiothoracic surgeons, 64.9% were White, 25.2% were Asian, 3.3% were Black or African American, 4.9% were Hispanic or Latino, and 1.7% were of other race or ethnicity. Cardiothoracic surgeons at the academic rank of professor were 74.6% White, 17.7% Asian, 3.4% Black or African American, 3.9% Hispanic or Latino, and 0.4% other races. Asian faculty earned 89% to 171%, Black or African American faculty earned 59% to 94%, and Hispanic or Latino faculty earned 84% to 165% of the median salary earned by White faculty. Black or African American faculty consistently and significantly (P = .002) earned lower median salaries compared with White faculty at each academic rank measured.

CONCLUSIONS

The academic cardiothoracic surgery workforce lacks diversity, especially at the highest academic ranks. Salary equity among races or ethnicities is complex, requiring additional study. However, Black or African American cardiothoracic surgeons experience low representation and salary disparity at every academic rank measured.

Primary healthcare providers' knowledge, practices and beliefs relating to preventive sexual and reproductive health care for women from refugee and asylum-seeking backgrounds in Australia: a national cross-sectional survey

Background Many refugee women and women seeking asylum arrive in high-income countries with unmet preventive sexual and reproductive health (SRH) care needs. Primary healthcare providers (HCPs) are usually refugee and asylum seekers' first point of care. This study aimed to identify HCP characteristics associated with initiating conversations and discussing SRH opportunistically during other health interactions. Methods An anonymous online survey was distributed nationally to representatives of health professional organisations and Primary Health Networks. Hierarchical logistic regression analysed factors including HCP demographics, knowledge and awareness, perceived need for training and professional experience with refugee women were included in the models. Results Among 163 HCPs, those initiating conversations ranged from 27.3% (contraceptive care) to 35.2% (cervical screening). Opportunistic discussions ranged from 26.9% (breast screening) to 40.3% (contraceptive care). Positively associated factors included offering care to refugee women or women seeking asylum at least once every 2months 7.64 (95% CI 2.41;24.22, P P P P P P Conclusions Direct professional experience, frequency of service provision, years of practice, and part time work positively influence HCPs' SRH care practices. Enhancing bilingual health worker programs, outreach, education, and support for SRH and cultural competency training are essential to improving the preventive SRH care of refugee women and women seeking asylum.

Risk management or racial Bias? The disparate use of restraints in the Emergency Department of an Urban Safety-Net Hospital

OBJECTIVES

Limited data exist on racial-ethnic differences in the application of restraints for patients visitng the emergency department (ED). This study examines whether there is an association between race and patient ED visit type with the application of four-point mechanical restraints in a high acuity safety-net urban academic hospital.

METHODS

The study retrospectively reviewed 198,610 visits to the ED at Boston Medical Center made by patients between 18 and 89 years old between May 1, 2014 and May 1, 2019. ED visit type was categorized based on primary billing code for the visit as either medical or behavioral; behavioral visits were further categorized into 5 groups based on corresponding primary psychiatric billing code category. The relationships between race/ethnicity and four-point mechanical restraints were analyzed using binary logistic regression models in SPSS.

RESULTS

1.4% of unique visits involved the use of four-point mechanical restraints. Patients with a behavioral visit were significantly over 16 times more likely to be restrained than those with a medical visit. Black patients were significantly more likely to be restrained than white patients for behavioral visits but less likely for medical visits. Black and Hispanic patients were also significantly more likely to be restrained for a behavioral visit regardless of psychiatric diagnosis. Asian patients were less likely to be restrained regardless of ED visit type.

CONCLUSIONS

Significant racial differences in restraints for White patients with medical visits and Black and Hispanic patients with behavioral visits prompts further investigation on the role of clinician bias when managing acute patients.

Empathy in Nutrition and Dietetics: A Scoping Review

BACKGROUND

Empathy is fundamental to the provision of efficacious patient-centered health care. Currently, there is no comprehensive synthesis of peer-reviewed empirical research related to empathy in the nutrition and dietetics profession. Understanding empathy in the context of nutrition and dietetics care may lead to improved teaching practices that support nutrition and dietetics students and practitioners to provide high-quality, empathic, patient-centered care.

OBJECTIVE

This scoping review aimed to understand the approaches through which empathy is conceptualized, measured, and taught in the field of nutrition and dietetics.

METHODS

Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses-Scoping Reviews Statement and Checklist, a scoping review process was undertaken. Five databases were searched in February 2023: Cumulative Index to Nursing and Allied Health, Embase, Medline, PsycInfo, and Scopus, with no date limits. Eligible studies were English language-based, peer-reviewed, empirical research exploring or measuring empathy as an outcome in primary data stratified to nutrition and dietetics. Extracted qualitative data were synthesized and analyzed thematically with an inductive, interpretivist approach applied to conceptualize the interrelationship between empathy and dietetic practice. Quantitative data were extracted and summarized in a table.

RESULTS

Twenty-six studies were included in the scoping review. Analysis identified 2 overarching themes underpinning the current literature on empathy in nutrition and dietetics that described empathy as a key skill in the application of patient-centered care, which was supported by approaches to lifelong cultivation of empathy in the nutrition and dietetics profession. A range of tools has measured empathy in nutrition and dietetics students and practitioners with no clear consensus in findings across studies.

CONCLUSIONS

This review identified the extent and nature of empathy within nutrition and dietetics, from both practitioner and patient perspectives, and the vast array of approaches used to teach and quantify empathy in students and practitioners. Insights from this review inform the need for future studies. The results of this review suggest that future research include exploring implications of empathic dietetics care on patient outcomes and identification of best practice, evidence-based curricula and strategies to support sustainable cultivation and maintenance of empathic care across the career span of nutrition and dietetics practitioners.

Low-Resource Hospital Days for Children Following New Tracheostomy

BACKGROUND AND OBJECTIVES

Children with new tracheostomy and invasive mechanical ventilation (IMV) require transitional care involving caregiver education and nursing support. To better understand hospital resource use during this transition, our study aimed to: (1) define and characterize low-resource days (LRDs) for this population and (2) identify factors associated with LRD occurrence.

METHODS

This retrospective cohort analysis included children ≤21 years with new tracheostomy and IMV dependence admitted to an ICU from 2017 to 2022 using the Pediatric Health Information System database. A LRD was defined as a post tracheostomy day that accrued nonroom charges <10% of each patient's accrued nonroom charges on postoperative day 1. Factors associated with LRDs were analyzed using negative binomial regression.

RESULTS

Among 4048 children, median post tracheostomy stay was 69 days (interquartile range 34-127.5). LRDs were common: 38.6% and 16.4% experienced ≥1 and ≥7 LRDs, respectively. Younger age at tracheostomy (0-7 days rate ratio [RR] 2.42 [1.67-3.51]; 8-28 days RR 1.8 (1.2-2.69) versus 29-365 days; Asian race (RR 1.5 [1.04-2.16]); early tracheostomy (0-7 days RR 1.56 [1.2-2.04]), and longer post tracheostomy hospitalizations (31-60 days RR 1.85 [1.44-2.36]; 61-90 days RR 2.14 [1.58-2.91]; >90 days RR 2.21 [1.71-2.86]) were associated with more LRDs.

CONCLUSIONS

Approximately 1 in 6 children experienced ≥7 LRDs. Younger age, early tracheostomy, Asian race, and longer hospital stays were associated with increased risk of LRDs. Understanding the postacute phase, including bed utilization, serves as an archetype to explore care models for children with IMV dependence.

Obtaining the Most Accurate, Explainable Model for Predicting Chronic Obstructive Pulmonary Disease: Triangulation of Multiple Linear Regression and Machine Learning Methods

BACKGROUND

Lung disease is a severe problem in the United States. Despite the decreasing rates of cigarette smoking, chronic obstructive pulmonary disease (COPD) continues to be a health burden in the United States. In this paper, we focus on COPD in the United States from 2016 to 2019.

OBJECTIVE

We gathered a diverse set of non-personally identifiable information from public data sources to better understand and predict COPD rates at the core-based statistical area (CBSA) level in the United States. Our objective was to compare linear models with machine learning models to obtain the most accurate and interpretable model of COPD.

METHODS

We integrated non-personally identifiable information from multiple Centers for Disease Control and Prevention sources and used them to analyze COPD with different types of methods. We included cigarette smoking, a well-known contributing factor, and race/ethnicity because health disparities among different races and ethnicities in the United States are also well known. The models also included the air quality index, education, employment, and economic variables. We fitted models with both multiple linear regression and machine learning methods.

RESULTS

The most accurate multiple linear regression model has variance explained of 81.1%, mean absolute error of 0.591, and symmetric mean absolute percentage error of 9.666. The most accurate machine learning model has variance explained of 85.7%, mean absolute error of 0.456, and symmetric mean absolute percentage error of 6.956. Overall, cigarette smoking and household income are the strongest predictor variables. Moderately strong predictors include education level and unemployment level, as well as American Indian or Alaska Native, Black, and Hispanic population percentages, all measured at the CBSA level.

CONCLUSIONS

This research highlights the importance of using diverse data sources as well as multiple methods to understand and predict COPD. The most accurate model was a gradient boosted tree, which captured nonlinearities in a model whose accuracy is superior to the best multiple linear regression. Our interpretable models suggest ways that individual predictor variables can be used in tailored interventions aimed at decreasing COPD rates in specific demographic and ethnographic communities. Gaps in understanding the health impacts of poor air quality, particularly in relation to climate change, suggest a need for further research to design interventions and improve public health.

The Role of Interactional Processes in Mental Health Disparities: A Narrative Review of Existing Research and Recommendations for Providers

Mental health disparities between racial/ethnic minority groups and non-Latinx Whites in the United States persist despite significant efforts aimed at decreasing these disparities. Efforts to address mental health disparities have largely focused on individual (e.g., stigma, help-seeking, health behaviors) and structural (e.g., public policy, interventions, addressing poverty) level factors. In contrast, this paper considers how processes at the interactional level (i.e., interactions between patients and providers) are also an important contributor to racial/ethnic disparities in mental health. Specifically, social psychological research has demonstrated how biases, including stereotypes, prejudice, and discrimination, can affect patient-provider interactions and contribute to mental health disparities. This narrative review of empirical studies that examine interactional processes between patients and mental health providers identified eleven studies to be included. Concepts represented in the studies are summarized and additional frameworks that can help explain how disparities are maintained are proposed. Last of all, practical suggestions for mitigating provider bias during patient-provider interactions are provided based on the findings from the narrative review.

"Racism Happens Every Day, All the Time": Black Families' Outpatient Experiences of Racism Across a Large Pediatric System

OBJECTIVE

To qualitatively understand and characterize the experience of racism in outpatient pediatric healthcare settings from the perspectives of Black families.

METHODS

We conducted focus groups with parents or guardians of Black children, recruited from academic primary care offices at a single pediatric institution. Focus groups were facilitated virtually by Black team members using an open-ended, semi-structured focus group guide. We analyzed focus group transcripts using iterative, thematic, inductive open coding performed independently by trained coders, with final codes reached by group consensus.

RESULTS

We conducted 6 focus groups of 3 to 5 participants each and 1 individual interview, with 24 total parents. We identified the following themes: 1) "I just felt like we was a number": Black families perceived experiences that felt impersonal and lacked empathy; 2) "Why is the doctor treating me like I don't matter?": Black families perceived experiences with poor care and worse treatment; 3) Black families experience racism across socioecological levels when interacting with pediatric health systems; 4) Positive perceived experiences can guide improvement; and 5) Improvement will require antiracist efforts across the levels of racism.

CONCLUSIONS

In this qualitative study, we found that Black families have had many poor pediatric experiences, perceive racism as affecting child health broadly across socioecological levels, and recommend a multidimensional antiracist approach to improvement. Our findings underscore the importance of elevating Black family voices in developing policies that prioritize antiracism and work to eliminate the harmful impacts of racism on child health.

Attitudes Toward Implicit Bias Among Athletic Trainers

Implicit biases are attitudes, emotions, or stereotypes that occur in an unconscious manner and have the potential to negatively affect behaviors, actions, and decisions. Recent studies have suggested that even when certain factors are controlled for, health care workers do not provide equitable care to patients from different demographics. When patients are not receiving equitable health care, there is a potential for disparities in patient-related outcomes. The purpose of this study was to determine attitudes toward implicit bias among athletic trainers. A secondary purpose of this study was to assess differences and correlations between attitudes toward implicit bias and demographic factors including age, years of experience, gender identity, sexual orientation, and race. Participants were recruited for this study by emailing athletic trainers from publicly available staff directories at institutions of higher education and high schools, and athletic training education program directors. The survey consisted of questions gathering demographic information and questions taken from the Attitudes Toward Implicit Bias Instrument. A total of 218 athletic trainers (age = 38 [11] y, years of certified experience = 14 [11] y) opened and completed the survey. On average, participants scored 71.0 [11.2] on the Attitudes Toward Implicit Bias Instrument. This mean score indicated that the average participant felt that implicit bias had the potential to negatively impact patient care and needed to be addressed through education. There was a significant, negligible negative correlation between age and attitudes toward implicit bias (r[216] = -.157, P = .02). Examining implicit bias among athletic trainers warrants further research to understand how implicit bias can negatively affect access to equitable health care opportunities. The development of high-quality interventions for identifying and addressing implicit bias is crucial to ensuring optimal patient outcomes in athletic training and all medical settings.

Understanding the Experiences of Latinx LGBTQ Texans at the Beginning of the COVID-19 Pandemic

Marginalized communities have been disproportionately affected by COVID-19, including both racial/ethnic minority and sexual minority populations. To date, there has been little research examining the impact of the COVID-19 pandemic at the intersections of marginalized identities. Furthermore, available national data on COVID-19 outcomes may obscure our understanding of region-specific outcomes, particularly in the U.S. South. Using an intersectional approach, we explore differences in worries over COVID-19, preventative behaviors, and COVID-19 outcomes in the early months of the pandemic in a diverse sample of LGBTQ people (N = 1076) living in Texas. Our findings indicated that LGBTQ Latinx people in Texas reported more COVID-19 related worries and adverse outcomes than non-Latinx LGBTQ people. These findings are in line with previous research that found that the increased risk to Latinx and LGBTQ populations in public health crises is often overlooked and can be attributed to many factors such as socioeconomic status, occupational propensity, disparities in physical health, and barriers to healthcare access. Furthermore, our findings suggest the necessity of utilizing an intersectional approach when examining the disproportionate burden marginalized communities face in public health crises.

Latine perspectives on the impact of family, perceptions of medication, health systems, incarceration, and housing on accessing opioid agonist therapy: A thematic analysis

INTRODUCTION

Opioid-related overdose deaths rates among Latine individuals are increasing rapidly and, in Massachusetts, have exceeded rates among non-Hispanic White individuals. Yet Latine individuals are less likely to receive opioid agonist therapies (OAT) methadone and buprenorphine, which have been demonstrated to prevent opioid deaths. Amid climbing Latine overdose rates, we lack qualitative data from Spanish-speaking people who use opioids about their views on and access to OAT. In this paper, we sought to assess variables affecting Latine individuals' initiation of OAT.

METHODS

We conducted 21 semi-structured interviews - half in Spanish - with Latine-identifying individuals recruited from four locations-three residential treatment sites and one city shelter-in Boston offering services to people who use drugs. We utilized thematic analysis to identify barriers and facilitators to starting and continuing OAT.

RESULTS

The following themes - which cut across individual-, interpersonal-, and systems-level variables - emerged as core considerations shaping Latine participants' OAT engagement: (1) family, (2) medication desirability and accessibility, (3) health care resources, (4) housing stability, and (5) incarceration. First, family members were prominent interpersonal influences on participants' treatment decisions. For some participants, family introduced participants to opioids at young ages and later supported them in recovery. Second, engagement with OAT was shaped by individual-level opinions on the medications as well as by systems-level experiences with trying to access the medications. Participants identified benefits and drawbacks of methadone versus buprenorphine, with greater access difficulties for methadone. Third, the health care setting in Boston provided notable systems-level facilitators to OAT access, including outreach workers, Medicaid, and Spanish-speaking providers. Fourth, housing instability impeded some from accessing OAT while motivating others to initiate the medications. Finally, incarceration created systems-level barriers to OAT engagement. Most participants had been incarcerated in jail or prison but did not have access to OAT during incarceration or during their transition back to the community.

CONCLUSIONS

Approaches to increase OAT engagement among Latine individuals should consider integrating family into recovery pathways, tailoring information in Spanish, developing bilingual/bicultural staffing, ensuring supportive insurance coverage systems, addressing housing needs, and making OAT available for individuals involved in the legal system.

The nature and validity of implicit bias training for health care providers and trainees: A systematic review

The number of health care educational institutions/organizations adopting implicit bias training is growing. Our systematic review of 77 studies (published 1 January 2003 through 21 September 2022) investigated how implicit bias training in health care is designed/delivered and whether gaps in knowledge translation compromised the reliability and validity of the training. The primary training target was race/ethnicity (49.3%); trainings commonly lack specificity on addressing implicit prejudice or stereotyping (67.5%). They involved a combination of hands-on and didactic approaches, lasting an average of 343.15 min, often delivered in a single day (53.2%). Trainings also exhibit translational gaps, diverging from current literature (10 to 67.5%), and lack internal (99.9%), face (93.5%), and external (100%) validity. Implicit bias trainings in health care are characterized by bias in methodological quality and translational gaps, potentially compromising their impacts.

Bridges between two medical realities: Perspectives of Indigenous medical and nursing students on snakebite care in the Brazilian Amazon

In the Brazilian Amazon, snakebite envenomations (SBEs) disproportionately affect Indigenous populations, and have a significantly higher incidence and lethality than in non-Indigenous populations. This qualitative study describes the Indigenous and biomedical healthcare domains for SBE care from the perspective of the Indigenous medical and nursing students in Manaus, Western Brazilian Amazon. In-depth interviews were conducted with five Indigenous students from the Amazonas State University, between January and December 2021. The interviews were analyzed using inductive content analysis. We organized an explanatory model with five themes: (1) participants' identities; (2) causality levels in Indigenous and biomedical systems; (3) therapeutic itineraries in Indigenous and biomedical systems; (4) ideological implications of adding biomedical devices to Indigenous healing systems; and (5) therapeutic failure in and efficacy of Indigenous and biomedical systems. From a noncolonial perspective and seeking to increase the quality and acceptability of health care for the Indigenous populations of the Brazilian Amazon, the training of Indigenous health professionals presents itself as a promising strategy. For this goal, universities should serve as empowering settings for Indigenous health students that support them in their growth and development, raise their awareness of injustice, and catalyze change toward a culturally adapted and effective service for the users.

Protective Assets Reinforced With Integrated Care and Technology (PARITY): Protocol for a Randomized Controlled Trial

BACKGROUND

Black women are significantly more likely to experience severe maternal morbidity and are 3 times as likely to die from pregnancy-related causes compared to White women. Using a strengths-based wellness approach within an integrated supportive care program provided by a community doula could offer pragmatic solutions for Black maternal disparities. The Protective Assets Reinforced with Integrated Care and Technology (PARITY) program consists of a wellness technology platform, including informational links to wellness content and reinforcing motivational SMS text messages, as well as community-based doula support delivered both in person and through the technology platform to improve Black maternal wellness.

OBJECTIVE

This pilot randomized controlled trial (RCT) and mixed methods evaluation aims to (1) determine the feasibility and acceptability of the PARITY intervention; (2) investigate the preliminary efficacy of the PARITY intervention on clinical outcomes (maternal blood pressure, gestational weight gain, and cesarean birth); and (3) investigate changes to wellness behavioral outcomes (nutrition, physical activity, sleep, and health care adherence) and empowered strengths (self-efficacy, social support, motivation, resilience, problem-solving, and self-regulation) in the intervention group compared to a control group.

METHODS

A 2-arm RCT and mixed methods evaluation will be conducted. Overall, 60 Black pregnant individuals will be randomized in a ratio of 1:1 to either the intervention or informational control group. Participants in the intervention group will receive access to the technology platform over a 12-week period that ends before birth. Intervention participants will be assigned a doula interventionist, who will meet with them 4 times during the intervention. All participants (intervention and control) will receive a referral for a birth doula at no cost, printed materials about having a healthy pregnancy, and community resources. Feasibility and acceptability will be assessed at the end of the program. Measures will be obtained at baseline (20-28 weeks), the 36th week of pregnancy, birth, and 6-12 weeks post partum. Summary statistics and distribution plots will be used to describe measured variables at each time point. A generalized linear mixed model with a shared random component will be used to analyze the effects of PARITY on clinical, wellness behavioral, and empowered strength outcomes, including baseline nutrition, physical activity, and sleep measures as covariates. For significant effects, post hoc contrasts will be adjusted using the Holm method to maintain comparison-wise error at or <.05. Missing data will be addressed using a pattern-mixture model.

RESULTS

The National Institute of Nursing Research funded this pilot RCT. Recruitment, enrollment, and data collection are ongoing, and the estimated study completion date is October 2024.

CONCLUSIONS

The expected results of this study will provide the feasibility and preliminary efficacy of the PARITY intervention, to be used in a larger trial with a 12-month PARITY program intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05802615; https://clinicaltrials.gov/study/NCT05802615.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/58580.

Are clinicians ethically obligated to disclose their use of medical machine learning systems to patients?

It is commonly accepted that clinicians are ethically obligated to disclose their use of medical machine learning systems to patients, and that failure to do so would amount to a moral fault for which clinicians ought to be held accountable. Call this 'the disclosure thesis.' Four main arguments have been, or could be, given to support the disclosure thesis in the ethics literature: the risk-based argument, the rights-based argument, the materiality argument and the autonomy argument. In this article, I argue that each of these four arguments are unconvincing, and therefore, that the disclosure thesis ought to be rejected. I suggest that mandating disclosure may also even risk harming patients by providing stakeholders with a way to avoid accountability for harm that results from improper applications or uses of these systems.

The Utility of the Social Vulnerability Index as a Proxy for Social Disparities Following Total Knee Arthroplasty

BACKGROUND

In 2021, alternative payment models accounted for 40% of traditional Medicare reimbursements. As such, we sought to examine health disparities through a standardized categorization of social disparity using the social vulnerability index (SVI). We examined (1) risk factors for SVI ≥ 0.50, (2) incidences of complications, and (3) risk factors for total complications between patients who have SVI < 0.50 and SVI ≥ 0.50 who had a total knee arthroplasty (TKA).

METHODS

Patients who underwent TKA between January 1, 2022 and December 31, 2022 were identified in the state of Maryland. A total of 4,952 patients who had complete social determinants of health data were included. Patients were divided into 2 cohorts according to SVI: < 0.50 (n = 2,431) and ≥ 0.50 (n = 2,521) based on the national mean SVI of 0.50. The SVI identifies communities that may need support caused by external stresses on human health based on 4 themed scores: socioeconomic status, household composition and disability, minority status and language, and housing and transportation. The SVI theme of household composition and disability encompassed patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies. The higher the SVI, the more social vulnerability or resources are needed to thrive in a geographic area.

RESULTS

When controlling for risk factors and patient comorbidities, the theme of household composition and disability (odds ratio 2.0, 95% confidence interval 1.1 to 5.0, P = .03) was the only independent risk factor for total complications. Patients who had an SVI ≥0.50 were more likely to be women (65.8% versus 61.0%, P < .001), Black (34.4% versus 12.9%, P < .001), and have a median household income < $87,999 (21.3% versus 10.2%, P < .001) in comparison to the patients who had an SVI < 0.50, respectively.

CONCLUSIONS

The SVI theme of household composition and disability, encompassing patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies, were independent risk factors for total complications following TKA. Together, these findings offer opportunities for interventions with selected patients to address social disparities.

Beyond the Question: Reexamining a Parent's Unusual Request

Pediatricians sometimes think about medical ethics as the field of determining right and wrong in in answering difficult moral questions that occur at the bedside. But an emphasis on rapidly determining right and wrong when faced with ethical dilemmas can lead clinicians to miss important issues underlying both the question and their approach to answering it. We argue that ethical reflection is not merely a process of getting to the right answer but also a way to probe beyond the original question to better understand the stakeholders' perspectives and priorities. In this Ethics Rounds, we present the case of an infant born at 23 weeks' gestation who initially faced numerous complications of prematurity, but has progressed beyond acute critical illness. His father requests a transition to palliative care at a point this option would not typically be offered. The straightforward response to this father's request is "no." However, we reexamine the father's request from the perspective of a neonatologist, a clinical ethicist, and a conflict mediator. Why is the father making this request? Why do clinicians feel rushed to respond? The authors discuss how elements of surprise and implicit biases can push clinicians to hasty answers. We introduce tools used in clinical ethics consultation and conflict mediation that can facilitate alternative responses from the clinical team. Employing the "Ladder of Inference," ascertaining the "View from Everywhere," and differentiating positions from interests can help clinicians explore the context of ethical questions and lead to more fruitful resolutions.

"Let Us Take Care of the Medicine": A Qualitative Analysis of Physician Communication When Caring for Febrile Infants

BACKGROUND

Guidelines for the management of febrile infants emphasize patient-centered communication. Although patient-centeredness is central to high-quality health care, biases may impact physicians' patient-centeredness. We aimed to 1) identify physicians' assumptions that inform their communication with parents of febrile infants and 2) examine physicians' perceptions of bias.

METHODS

We recruited physicians from 3 academic pediatric emergency departments (EDs) for semistructured interviews. We applied a constant comparative method approach to conduct a thematic analysis of interview transcripts. Two coders followed several analytical steps: 1) discovery of concepts and code assignment, 2) identification of themes by grouping concepts, 3) axial coding to identify thematic properties, and 4) identifying exemplar excerpts for rich description. Thematic saturation was based on repetition, recurrence, and forcefulness.

RESULTS

Fourteen physicians participated. Participants described making assumptions regarding 3 areas: 1) the parent's affect, 2) the parent's social capacity, and 3) the physician's own role in the parent-physician interaction. Thematic properties highlighted the importance of the physician's assumptions in guiding communication and decision-making. Participants acknowledged an awareness of bias and specifically noted that language bias influenced the assumptions that informed their communication.

CONCLUSIONS

ED physicians described subjective assumptions about parents that informed their approach to communication when caring for febrile infants. Given the emphasis on patient-centered communication in febrile infant guidelines, future efforts are necessary to understand how assumptions are influenced by biases, the effect of such behaviors on health inequities, and how to combat this.

Racial and ethnic disparities in Lyme disease in the United States

INTRODUCTION

Lyme disease (LD), caused by the spirochete Borrelia burgdorferi, is the most common vector-borne disease in the United States. Although most surveillance-reported cases are in people who are White, data suggest worse outcomes among people from racial and ethnic minority groups.

METHODS

We conducted a systematic literature review to describe racial disparities in LD. We described the epidemiology of LD by race and ethnicity, including clinical presentation at diagnosis, and summarised the literature on knowledge, attitudes and practices related to LD and ticks by race and ethnicity.

RESULTS

Overall, the incidence and prevalence of LD were 1.2-3.5 times higher in White persons than in persons who identified as Asian or Pacific Islander and 4.5-6.3 times higher in White persons than in persons who identified as Black. Across multiple studies, people from racial and ethnic minority groups were more likely than White people to have disseminated manifestations of LD, including neurological manifestations and arthritis, and less likely to have erythema migrans. People from racial and ethnic minority groups were also more likely to report disease onset in the fall and less likely to report disease onset in the summer. Possible reasons for these disparities include lack of recognition of the disease in people with darker skin tones, lack of knowledge of disease risk for some groups and differences in exposure risk.

CONCLUSIONS

Taken together, these results reinforce that all people residing in high-incidence areas are at risk of LD, regardless of race or ethnicity. Future prevention measures should be broadly targeted to reach all at-risk populations.

Racial and Ethnic Disparities in Otolaryngology Office Visit and Tympanostomy Tube Placement in Children with Otitis Media

OBJECTIVES

Racial disparities are pervasive in access to pediatric surgery. The goal of this study was to test the hypotheses that, compared with White children, non-White and Hispanic children: (1) were less likely to attend evaluations by otolaryngologists after a diagnosis of otitis media (OM) eligible for surgical referral, and (2) these children were less likely to receive tympanostomy tube (TT) after surgical consultation.

METHODS

The OptumLabs Data Warehouse is a de-identified claims database of privately insured enrollees. Guidelines on the management of OMs suggest that children should be evaluated for surgery if they have recurrent acute OM or chronic OM with effusion. A cohort of children who were diagnosed with OM were constructed. For Hypothesis 1, the primary outcome was otolaryngology office visit within 6 months of a diagnosis of recurrent or chronic OM. For Hypothesis 2, the outcome was TT placement within 6 months following the otolaryngology office visit. Cox regression models were used to determine the relationship between race/ethnicity and the primary outcomes.

RESULTS

Among 187,776 children with OMs, 72,774 (38.8%) had otolaryngology visits. In a multivariate Cox model, the hazard ratios of attending otolaryngology visit for Black, Hispanic, and Asian children were 0.93 (95% CI,0.90, 0.96), 0.86 (0.83, 0.88), and 0.74 (0.71, 0.77), compared with White children. Among the children evaluated by otolaryngologists, 46,554 (63.97%) received TT. Black, Hispanic, and Asian children with recurrent acute OM had lower likelihood of receiving TT.

CONCLUSIONS

Racial disparities in attending otolaryngology office visit contributed to the disparities in receiving TT.

QUALITY OF EVIDENCE

Level 3 Laryngoscope, 134:3846-3852, 2024.

Using case vignettes to study the presence of outcome, hindsight, and implicit bias in acute unplanned medical care: a cross-sectional study

BACKGROUND AND IMPORTANCE

Various biases can impact decision-making and judgment of case quality in the Emergency Department (ED). Outcome and hindsight bias can lead to wrong retrospective judgment of care quality, and implicit bias can result in unjust treatment differences in the ED based on irrelevant patient characteristics.

OBJECTIVES

First, to evaluate the extent to which knowledge of an outcome influences physicians' quality of care assessment. Secondly, to examine whether patients with functional disorders receive different treatment compared to patients with a somatic past medical history.

DESIGN

A web-based cross-sectional study in which physicians received case vignettes with a case description and care provided. Physicians were informed about vignette outcomes in a randomized way (no, good, or bad outcome). Physicians rated quality of care for four case vignettes with different outcomes. Subsequently, they received two more case vignettes. Physicians were informed about the past medical history of the patient in a randomized way (somatic or functional). Physicians made treatment and diagnostic decisions for both cases.

SETTING AND PARTICIPANTS

One hundred ninety-one Dutch emergency physicians (EPs) and general practitioners (GPs) participated.

OUTCOME MEASURES AND ANALYSIS

Quality of care was rated on a Likert scale (0-5) and dichotomized as adequate (yes/no). Physicians estimated the likelihood of patients experiencing a bad outcome for hindsight bias. For the second objective, physicians decided on prescribing analgesics and additional diagnostic tests.

MAIN RESULTS

Large differences existed in rated quality of care for three out of four vignettes based on different case outcomes. For example, physicians rated the quality of care as adequate in 44% (95% CI 33-57%) for an abdominal pain case with a bad outcome, compared to 88% (95% CI 78-94%) for a good outcome, and 84% (95% CI 73-91%) for no outcome ( P  < 0.01). The estimated likelihood of a bad outcome was higher if physicians received a vignette with a bad patient outcome. Fewer diagnostic tests were performed and fewer opioids were prescribed for patients with a functional disorder.

CONCLUSION

Outcome, hindsight, and implicit bias significantly influence decision-making and care quality assessment by Dutch EPs and GPs.

Race and Ethnicity and Diagnostic Testing for Common Conditions in the Acute Care Setting

Importance

Overuse of diagnostic testing is pervasive, but the extent to which it varies by race and ethnicity in the acute care setting is poorly understood.

Objective

To use a previously validated diagnostic intensity index to evaluate differences in diagnostic testing rates by race and ethnicity in the acute care setting, which may serve as a surrogate for diagnostic test overuse.

Design, Setting, and Participants

This was a cross-sectional study of emergency department (ED) discharges, hospital observation stays, and hospital admissions using administrative claims among EDs and acute care hospitals in Kentucky, Maryland, North Carolina, and New Jersey, from 2016 through 2018. The diagnostic intensity index pairs nonspecific principal discharge diagnoses (nausea and vomiting, abdominal pain, chest pain, and syncope) with related diagnostic tests to estimate rates of nondiagnostic testing. Adults with an acute care encounter with a principal discharge diagnosis of interest were included. Data were analyzed from January to February 2024.

Exposure

Race and ethnicity (Asian, Black, Hispanic, White, other [including American Indian, multiracial, and multiethnic], and missing).

Main Outcomes and Measures

Receipt of a diagnostic test. Generalized linear models with a hospital-specific indicator variable were estimated to calculate the adjusted odds ratio of receiving a test related to the principal discharge diagnosis by race and ethnicity, controlling for primary payer and zip code income quartile.

Results

Of 3 683 055 encounters (1 055 575 encounters [28.7%] for Black, 300 333 encounters [8.2%] for Hispanic, and 2 140 335 encounters [58.1%] for White patients; mean [SD] age of patients with encounters, 47.3 [18.8] years; 2 233 024 encounters among females [60.6%]), most (2 969 974 encounters [80.6%]) were ED discharges. Black compared with White patients discharged from the ED with a diagnosis of interest had an adjusted odds ratio of 0.74 (95% CI, 0.72-0.75) of having related diagnostic testing. No other racial or ethnic disparities of a similar magnitude were observed in any acute care settings.

Conclusions and Relevance

In this study, White patients discharged from the ED with a nonspecific diagnosis of interest were significantly more likely than Black patients to receive related diagnostic testing. The extent to which this represents diagnostic test overuse in White patients vs undertesting and missed diagnoses in Black patients deserves further study.

Trends in Epidemiology and Treatment of Humerus Fractures in the United States, 2017-2022

Background Fractures of the humerus are one of the more common fractures in the United States and a cause of fragility fractures in the elderly population. This study aims to understand recent trends in the demographic factors correlated with humeral shaft fractures (HSF) and humeral shaft fracture nonunion (HSFN) following open reduction internal fixation (ORIF) and intramedullary nailing (IMN). Methods The TriNetX database was used to query using International Classification of Diseases-10 (ICD10) diagnosis codes for patients who sustained HSF between 2017 and 2022. Patients were then organized into cohorts based on Current Procedural Terminology (CPT) codes 24515 and 24516 for ORIF and IMN of HSFs, respectively. Subsequent nonunion after operative management was queried. Descriptive and comparative analysis was performed to examine the differences observed between patients based on age, sex, ethnicity, race, and smoking status as well as surgical management across the six-year study period. Results The incidence of HSF increased from 7,108 in 2017 to 8,450 in 2022. The rate of HSF ORIF increased from 12% to 17% while the nonunion rate following ORIF decreased from 4% to 3%. The rate of HSF IMN increased from 4% to 6% and the rate of nonunion following IMN increased from 2% to 4%. The overall rate of HSFN surgery was 1.7% with slight decreasing trend over the past year. Conclusion It is speculated that improved care and surgical indications resulted in a lower rate of nonunion despite an increase in the overall rate of HSF and its operative managements.

Gender and race-related disparities in the management of ventricular arrhythmias

Modern studies have revealed gender and race-related disparities in the management and outcomes of cardiac arrhythmias, but few studies have focused on outcomes for ventricular arrhythmias (VAs) such as ventricular tachycardia (VT) or ventricular fibrillation (VF). The aim of this article is to review relevant studies and identify outcome differences in the management of VA among Black and female patients. We found that female patients typically present younger for VA, are more likely to have recurrent VA after catheter ablation, are less likely to be prescribed antiarrhythmic medication, and are less likely to receive primary prevention ICD placement as compared to male patients. Additionally, female patients appear to derive similar overall mortality benefit from primary prevention ICD placement as compared to male patients, but they may have an increased risk of acute post-procedural complications. We also found that Black patients presenting with VA are less likely to undergo catheter ablation, receive appropriate primary prevention ICD placement, and have significantly higher risk-adjusted 1-year mortality rates after hospital discharge as compared to White patients. Black female patients appear to have the worst outcomes out of any demographic subgroup.

Caregiver and Provider Perceptions of Health Disparities in the NICU: A Qualitative Study

OBJECTIVES

To describe the experience of caregivers and their perceptions of disparate care in the NICU, and (2) explore inter-professional NICU provider perspectives on potential biases and perceptions of disparate care.

METHODS

This qualitative study was conducted in one southeastern level IV NICU. Semi-structured interviews assessed caregiver and provider perspectives on NICU care. Purposive sampling ensured ≥50% of caregivers self-identified as racial and/or ethnic minorities. Interviews were recorded, transcribed verbatim, and audio verified. A coding scheme was developed, raw data were systematically coded, and emerging themes were identified using thematic analyses.

RESULTS

23 caregivers and 14 providers were interviewed, including 5 neonatologists, 6 nurses, and 3 residents. Caregivers were predominantly English-speaking (85%); 96% were mothers with a mean age of 32 years. Neonates were predominantly racial and ethnic minorities (62%). Providers were predominantly White (71%) and female (71%). Five themes emerged: (1) ineffective, biased communication between caregivers, providers, and healthcare team may contribute to disparities (2) language barriers and lack of interpreter access play a significant role in perceived negative care; (3) lack of caregiver involvement and role in decision-making may negatively influence NICU outcomes, especially for those not able to be present at the bedside; and (4) multiple biases may affect neonatal health disparities.

CONCLUSION

Our study highlights the importance of considering both provider and racial and/or ethnic minority caregiver perceptions disparities in NICU care delivery. It adds to the literature as one of the few qualitative studies comparing perceptions of disparate NICU care among both caregivers and providers.

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.

Advancing health equity in the aftermath of COVID-19: Confronting intensifying racial disparities

The COVID-19 pandemic has exposed and exacerbated the persistent racial and ethnic health disparities in the United States. The pandemic has also had profound spillover effects on other aspects of health and wellbeing, such as mental health, chronic diseases, education, and income, for marginalized groups. In this article, we provide a thorough analysis of the pandemic's impact on racial and ethnic health disproportionalities, highlighting the multifaceted and interrelated factors that contribute to these inequities. We also argue for a renewed focus on health equity in healthcare policy and practice, emphasizing the need for systemic changes that address both the immediate and long-term consequences of these imbalances. We propose a framework for achieving health equity that involves creating equitable systems, care, and outcomes for all individuals, regardless of their race or ethnicity.

Evaluating parental personal utility of pediatric genetic and genomic testing in a diverse, multilingual population

There is increasing evidence of the clinical utility of genetic and genomic testing (GT); however, factors influencing personal utility of GT, especially in diverse, multilingual populations, remain unclear. We explored these factors in a diverse cohort of parents/guardians (participants) whose children received clinical GT through the NYCKidSeq program. A total of 847 participants completed surveys at baseline, post-results disclosure, and 6 months (6m) post-results. The largest population groups were Hispanic/Latino(a) (48%), White/European American (24%), and Black/African American (16%). Personal utility was assessed using the Personal Utility (PrU) scale, adapted for pediatric populations and included on the surveys. Three PrU subscales were identified using factor analysis: practical, educational, and parental psychological utility. Overall personal utility summary score and the three subscales significantly decreased after receiving results and over time. Hispanic/Latino(a) participants identified greater overall personal utility than European American and African American participants at all time points (p < 0.001) as did participants whose children received positive/likely positive results compared with those with negative and uncertain results (post-results: p < 0.001 and p < 0.001; 6m post-results: p = 0.002 and p < 0.001, respectively). Post-results, higher subscale scores were associated with lower education levels (practical, parental psychological: p ≤ 0.02) and higher levels of trust in the healthcare system (practical, parental psychological: p ≤ 0.04). These findings help to understand the perspectives of diverse parents/guardians, which is critical to tailoring pre- and post-test counseling across a variety of populations and clinical settings.

Provider Implicit Racial Bias in Pediatric Sickle Cell Disease

BACKGROUND/OBJECTIVES

This study is to (1) assess implicit racial bias among pediatric providers and (2) use virtual patient (VP) vignettes to determine the impact of implicit racial bias on clinical decision-making in pediatric sickle cell disease (SCD) pain care.

DESIGN/METHODS

This cross-sectional study was conducted at a mid-sized, freestanding children's hospital in the northeast. Participants (N = 52) were pediatric SCD providers (87% cisgender female, 90% White, M age = 38.78). Providers completed a demographic questionnaire, the race Implicit Association Test (IAT) with adult and child faces, and a measure of SCD explicit bias (5-point Likert scale). Providers also made clinical decisions for four VP vignettes depicting Black and White youth in the emergency department (ED) with either SCD or cancer pain. Frequency tables were calculated.

RESULTS

On the race IAT, providers demonstrated a pro-White implicit bias for both adult (81%) and child (89%) faces. Responses to the explicit bias measure reflected low levels of agreement with negative stereotypes about SCD patients. No significant differences emerged in providers' pain treatment decisions for Black vs. White, or SCD vs. cancer VPs.

CONCLUSIONS

Findings indicate pediatric providers harbor implicit racial bias similar to the general population. Findings from VP vignettes did not demonstrate that pain treatment decision-making differed based on race or diagnosis. This may be due to standardized protocols and procedures in the pediatric emergency setting. Future research is needed to clarify the role of implicit bias in clinical decision-making and the potential efficacy of treatment protocols in preventing biases from interfering with pediatric SCD pain care.