Racial Differences in Shared Decision-Making About Critical Illness

Importance

Shared decision-making is the preferred method for evaluating complex tradeoffs in the care of patients with critical illness. However, it remains unknown whether critical care clinicians engage diverse patients and caregivers equitably in shared decision-making.

Objective

To compare critical care clinicians' approaches to shared decision-making in recorded conversations with Black and White caregivers of patients with critical illness.

Design, Setting, and Participants

This thematic analysis consisted of unstructured clinician-caregiver meetings audio-recorded during a randomized clinical trial of a decision aid about prolonged mechanical ventilation at 13 intensive care units in the US. Participants in meetings included critical care clinicians and Black or White caregivers of patients who underwent mechanical ventilation. The codebook included components of shared decision-making and known mechanisms of racial disparities in clinical communication. Analysts were blinded to caregiver race during coding. Patterns within and across racial groups were evaluated to identify themes. Data analysis was conducted between August 2021 and April 2023.

Main Outcomes and Measures

The main outcomes were themes describing clinician behaviors varying by self-reported race of the caregivers.

Results

The overall sample comprised 20 Black and 19 White caregivers for a total of 39 audio-recorded meetings with clinicians. The duration of meetings was similar for both Black and White caregivers (mean [SD], 23.9 [13.7] minutes vs 22.1 [11.2] minutes, respectively). Both Black and White caregivers were generally middle-aged (mean [SD] age, 47.6 [9.9] years vs 51.9 [8.8] years, respectively), female (15 [75.0%] vs 14 [73.7%], respectively), and possessed a high level of self-assessed health literacy, which was scored from 3 to 15 with lower scores indicating increasing health literacy (mean [SD], 5.8 [2.3] vs 5.3 [2.0], respectively). Clinicians conducting meetings with Black and White caregivers were generally young (mean [SD] age, 38.8 [6.6] years vs 37.9 [8.2] years, respectively), male (13 [72.2%] vs 12 [70.6%], respectively), and White (14 [77.8%] vs 17 [100%], respectively). Four variations in clinicians' shared decision-making behaviors by caregiver race were identified: (1) providing limited emotional support for Black caregivers, (2) failing to acknowledge trust and gratitude expressed by Black caregivers, (3) sharing limited medical information with Black caregivers, and (4) challenging Black caregivers' preferences for restorative care. These themes encompass both relational and informational aspects of shared decision-making.

Conclusions and Relevance

The results of this thematic analysis showed that critical care clinicians missed opportunities to acknowledge emotions and value the knowledge of Black caregivers compared with White caregivers. These findings may inform future clinician-level interventions aimed at promoting equitable shared decision-making.

Scalable Strategies to Increase Efficiency and Augment Public Health Activities During Epidemic Peaks

OBJECTIVE

Scalable strategies to reduce the time burden and increase contact tracing efficiency are crucial during early waves and peaks of infectious transmission.

DESIGN

We enrolled a cohort of SARS-CoV-2-positive seed cases into a peer recruitment study testing social network methodology and a novel electronic platform to increase contact tracing efficiency.

SETTING

Index cases were recruited from an academic medical center and requested to recruit their local social contacts for enrollment and SARS-CoV-2 testing.

PARTICIPANTS

A total of 509 adult participants enrolled over 19 months (384 seed cases and 125 social peers).

INTERVENTION

Participants completed a survey and were then eligible to recruit their social contacts with unique "coupons" for enrollment. Peer participants were eligible for SARS-CoV-2 and respiratory pathogen screening.

MAIN OUTCOME MEASURES

The main outcome measures were the percentage of tests administered through the study that identified new SARS-CoV-2 cases, the feasibility of deploying the platform and the peer recruitment strategy, the perceived acceptability of the platform and the peer recruitment strategy, and the scalability of both during pandemic peaks.

RESULTS

After development and deployment, few human resources were needed to maintain the platform and enroll participants, regardless of peaks. Platform acceptability was high. Percent positivity tracked with other testing programs in the area.

CONCLUSIONS

An electronic platform may be a suitable tool to augment public health contact tracing activities by allowing participants to select an online platform for contact tracing rather than sitting for an interview.

Characterization of agronomic traits and markers of recombinant inbred lines from intra- and interracial populations of Phaseolus vulgaris L

The value of intra- and interracial populations in common bean (Phaseolus vulgaris L.) needs to be determined in order to create useful genetic variation for maximizing gains from selection, broadening the genetic base of commercial cultivars, and making efficient use of available resources. Five large-seeded parents of race Nueva Granada (N), two small-seeded race Mesoamerica (M), and one medium-seeded race Durango (D) were hybridized to produce one intraracial (N x N) and three interracial (two N x M and one N x D) populations. Seventy-nine F2-derived F6 lines randomly taken from each population along with their parents were evaluated for agronomic traits and markers at Palmira and Popayán, Colombia, in 1990 and 1991. Variation for agronomic traits and for morphological, protein, and isozyme markers was larger in interracial populations than in the intraracial population. Mean seed yield of all lines as well as yield of the highest yielding line from two interracial populations were significantly higher than that of the intraracial population. The highest (≥ 0.80±0.15) heritability was recorded for 100-seed weight. Values for seed yield varied from 0.19±0.17 to 0.50±0.16. Gains from selection (at 20% selection pressure) for seed yield ranged from 3.9% to 11.4%. Seed yield was positively associated with biomass yield, pods/m(2), and days to maturity, but harvest index showed negative correlations with these traits and a positive value with 100-seed weight. Polymorphism was recorded for phaseolin, lectins, protein Group-1 and protein Group-2 fractions, and six isozyme loci. Lines with indeterminate growth habit had significantly (P < 0.01) higher seed yield than lines with determinate growth habit in a Redkloud x MAM 4 population. Also, 23 other associations of markers with agronomic traits other than seed yield were recorded. Of these associations, lines with T phaseolin, the Diap1 (2) allele, and lilac flower color tended to possess greater seed weight.