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BackgroundStudies suggest that black patients have better interactions, on average, with physicians of their own race. Whether this reflects greater “cultural competence” in race-concordant relationships, or other effects of race unrelated to physician behavior, is unclear. It is also unclear if physician race influences patient decision-making.ObjectiveTo determine whether physician race affects patients’ ratings of physicians and decision-making, independent of physician behavior.DesignRandomized study using standardized video vignettes.ParticipantsPrimary care patients with coronary risk factors or disease.InterventionsEach participant viewed one of 16 vignettes depicting a physician reviewing cardiac catheterization results and recommending coronary artery bypass graft (CABG) surgery. Vignettes varied only in terms of physicians’ race, gender, age, and communication style (high vs. low patient-centeredness).Main MeasuresParticipants rated the video physician’s communication, interpersonal style, competence, trustworthiness, likability, and overall performance (0–4 Likert scales). They also rated the necessity of CABG (0–5 scale) and whether they would undergo CABG or obtain a second opinion if they were the video patient (0–3 scales).Key ResultsParticipants included 107 black and 131 white patients (72% participation rate). Black participants viewing a black (vs. white) video physician gave higher ratings on all physician attributes (e.g., overall rating 3.22 vs. 2.34, p < 0.001) and were more likely to perceive CABG as necessary (4.05 vs. 3.72, p = 0.03) and say they would undergo CABG if they were the video patient (2.43 vs. 2.09, p = 0.004). Patient-centered communication style reduced, but did not eliminate, the impact of race concordance. Physician race was not associated with any outcomes among white patients.ConclusionsBlack patients viewed the doctor in a scripted vignette more positively, and were more receptive to the same recommendation, communicated in the same way, with a black vs. white physician. Patient-centered communication reduced but did not eliminate the effect of physician race.

BackgroundBlack Americans and women report feeling doubted or dismissed by health professionals.ObjectiveTo identify linguistic mechanisms by which physicians communicate disbelief of patients in medical records and then to explore racial and gender differences in the use of such language.DesignCross-sectional.Setting/ParticipantsAll notes for patients seen in an academic ambulatory internal medicine practice in 2017.Main MeasuresA content analysis of 600 clinic notes revealed three linguistic features suggesting disbelief: (1) quotes (e.g., had a “reaction” to the medication); (2) specific “judgment words” that suggest doubt (e.g., “claims” or “insists”); and (3) evidentials, a sentence construction in which patients’ symptoms or experience is reported as hearsay. We used natural language processing to evaluate the prevalence of these features in the remaining notes and tested differences by race and gender, using mixed-effects regression to account for clustering of notes within patients and providers.Key ResultsOur sample included 9251 notes written by 165 physicians about 3374 unique patients. Most patients were identified as Black (74%) and female (58%). Notes written about Black patients had higher odds of containing at least one quote (OR 1.48, 95% CI 1.20–1.83) and at least one judgment word (OR 1.25, 95% CI 1.02–1.53), and used more evidentials (β 0.32, 95% CI 0.17–0.47), compared to notes of White patients. Notes about female vs. male patients did not differ in terms of judgment words or evidentials but had a higher odds of containing at least one quote (OR 1.22, 95% CI 1.05–1.44).ConclusionsBlack patients may be subject to systematic bias in physicians’ perceptions of their credibility, a form of testimonial injustice. This is another potential mechanism for racial disparities in healthcare quality that should be further investigated and addressed.

The paper sets forth a set of evidence-based recommendations for interventions to combat unintentional bias among health care providers, drawing upon theory and research in social cognitive psychology. Our primary aim is to provide a framework that outlines strategies and skills, which can be taught to medical trainees and practicing physicians, to prevent unconscious racial attitudes and stereotypes from negatively influencing the course and outcomes of clinical encounters. These strategies and skills are designed to: 1) enhance internal motivation to reduce bias, while avoiding external pressure; 2) increase understanding about the psychological basis of bias; 3) enhance providers' confidence in their ability to successfully interact with socially dissimilar patients; 4) enhance emotional regulation skills; and 5) improve the ability to build partnerships with patients. We emphasize the need for programs to provide a nonthreatening environment in which to practice new skills and the need to avoid making providers ashamed of having racial, ethnic, or cultural stereotypes. These recommendations are also intended to provide a springboard for research on interventions to reduce unintentional racial bias in health care.

BackgroundHome-Based Primary Care (HBPC) has demonstrated success in decreasing risk of hospitalization and improving patient satisfaction through patient targeting and integrating long-term services and supports. Less is known about how HBPC teams approach social factors.ObjectiveDescribe HBPC providers’ knowledge of social complexity among HBPC patients and how this knowledge impacts care delivery.Design, Setting, and ParticipantsBetween 2018 and 2019, we conducted in-person semi-structured interviews with 14 HBPC providers representing nursing, medicine, physical therapy, pharmacy, and psychology, at an urban Veterans Affairs (VA) medical center. We also conducted field observations of 6 HBPC team meetings and 2 home visits.ApproachWe employed an exploratory, content-driven approach to qualitative data analysis.ResultsFour thematic categories were identified: (1) HBPC patients are socially isolated and have multiple layers of medical and social complexity that compromise their ability to use clinic-based care; (2) providers having “eyes in the home” yields essential information not accessible in outpatient clinics; (3) HBPC fills gaps in instrumental support, many of which are not medical; and (4) addressing social complexity requires a flexible care design that HBPC provides.Conclusion and RelevanceHBPC providers emphasized the importance of having “eyes in the home” to observe and address the care needs of homebound Veterans who are older, socially isolated, and have functional limitations. Patient selection criteria and discharge recommendations for a resource-intensive program like VA HBPC should include considerations for the compounding effects of medical and social complexity. Additionally, staffing that provides resources for these effects should be integrated into HBPC programming.

BackgroundData suggest that there were disparities in H1N1 vaccine uptake, and these may inform COVID-19 vaccination efforts. We conducted a systematic review to evaluate disparities in H1N1 vaccine uptake, factors contributing to disparities, and interventions to reduce them.MethodsWe searched English-language articles in MEDLINE ALL, PsycINFO, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from database inception through May 8, 2020. Observational studies examining H1N1 vaccine uptake by race/ethnicity, socioeconomic status, rurality, and disability status in US settings were included. Two reviewers independently assessed study eligibility. Single-reviewer data abstraction was confirmed by a second reviewer. We conducted independent dual quality assessment, and collective strength of evidence assessment.ResultsWe included 21 studies. African American/Black, Latino, and low-socioeconomic status participants had disproportionately lower H1N1 vaccination rates (low- to moderate-strength evidence). However, Latinos were more likely than Whites to intend to be vaccinated, and African American/Blacks and participants with lower-socioeconomic status were just as likely to intend to be vaccinated as their White and higher-socioeconomic status counterparts (low-strength evidence). Vaccine uptake for other groups has been insufficiently studied. Factors potentially contributing to disparities in vaccine uptake included barriers to vaccine access, inadequate information, and concerns about vaccine safety and efficacy. Studies were largely cross-sectional. Many of the studies are a decade old and were conducted in the context of a different pandemic. The categorization of racial and ethnic groups was not consistent across studies and not all groups were well-studied.DiscussionEfforts to avoid disparities in COVID-19 vaccination uptake should prioritize vaccine accessibility and convenience in African American/Black, Latino, and low-SES communities; engage trusted stakeholders to share vaccine information; and address concerns about vaccine safety and efficacy.Primary Funding SourceDepartment of Veterans Affairs, Veterans Health Administration, Health Services Research & Development.Protocol RegistrationPROSPERO CRD42020187078

Black patients disproportionately report feeling disbelieved or having concerns dismissed in medical encounters, suggesting potential racial bias in clinicians' assessment of patient credibility. Because this bias may be evident in the language used by clinicians when writing notes about patients, we sought to assess racial differences in use of language either undermining or supporting patient credibility within the electronic health record (EHR). We analyzed 13,065,081 notes written between 2016-2023 about 1,537,587 patients by 12,027 clinicians at a large health system with 5 hospitals and an extensive network of ambulatory practices in the mid-Atlantic region of the United States. We developed and applied natural language processing models to identify whether or not a note contained terms undermining or supporting patient credibility, and used logistic regression with generalized estimating equations to estimate the association of credibility language with patient race/ethnicity. The mean patient age was 43.3 years and 55.9% were female; 57.6% were non-Hispanic White, 28.0% non-Hispanic Black, 8.3% Hispanic/Latino, and 6.1% Asian. Clinician-authors were attending physicians (44.9%), physicians-in-training (40.1%) and advanced practice providers (15.0%). Terms specifically related to patient credibility were relatively uncommon, with 106,523 (0.82%) notes containing terms undermining patient credibility, and 33,706 (0.26%) supporting credibility. In adjusted analyses, notes written about non-Hispanic Black vs. White patients had higher odds of containing terms undermining credibility (aOR 1.29, 95% CI 1.27-1.32), and lower odds of supporting credibility (aOR 0.82; 95% CI 0.79-0.85). Notes written about Hispanic/Latino vs. White patients had similar odds of language undermining (aOR 0.99, 95% CI 0.95-1.03) and supporting credibility (aOR 0.95, 95% CI 0.89-1.02). Notes written about Asian vs. White patients had lower odds of language undermining credibility (aOR 0.85, 95% CI 0.81-0.89), and higher odds of supporting credibility (aOR 1.30, 95% CI 1.23-1.38). Clinician documentation undermining patient credibility may disproportionately stigmatize Black individuals and favor Asian individuals. As stigmatizing language in medical records has been shown to negatively influence clinician attitudes and decision making, these racial differences in documentation may influence patient care and outcomes and exacerbate health inequities.

ObjectiveTo describe how access to primary and specialty care differs for Medicaid patients relative to commercially insured patients, and how these differences vary across rural and urban counties, using comprehensive claims data from Oregon.DesignCross-sectional study of risk-adjusted access rates for two types of primary care providers (physicians; nurse practitioners (NPs) and physician assistants (PAs)); four types of mental health providers (psychiatrists, psychologists, advanced practice NPs or PAs specializing in mental health care, behavioral specialists); and four physician specialties (obstetrics and gynecology, general surgery, gastroenterology, dermatology).Participants420,947 Medicaid and 638,980 commercially insured adults in Oregon, October 2014–September 2015.OutcomePresence of any visit with each provider type, risk-adjusted for sex, age, and health conditions.ResultsRelative to commercially insured individuals, Medicaid enrollees had lower rates of access to primary care physicians (− 11.82%; CI − 12.01 to − 11.63%) and to some specialists (e.g., obstetrics and gynecology, dermatology), but had equivalent or higher rates of access to NPs and PAs providing primary care (4.33%; CI 4.15 to 4.52%) and a variety of mental health providers (including psychiatrists, NPs and PAs, and other behavioral specialists). Across all providers, the largest gaps in Medicaid-commercial access rates were observed in rural counties. The Medicaid-commercial patient mix was evenly distributed across primary care physicians, suggesting that access for Medicaid patients was not limited to a small subset of primary care providers.ConclusionsThis cross-sectional study found lower rates of access to primary care physicians for Medicaid enrollees, but Medicaid-commercial differences in access rates were not present across all provider types and displayed substantial variability across counties. Policies that address rural-urban differences as well as Medicaid-commercial differences—such as expansions of telemedicine or changes in the workforce mix—may have the largest impact on improving access to care across a wide range of populations.

Background Early readmission amongst older safety-net hospitalized adults is costly. Interventions to prevent early readmission have had mixed success. The role of perceived social support is unclear. We examined the association of perceived social support in 30-day readmission or death in older adults admitted to a safety-net hospital. Methods This is an observational cohort study derived from the Support From Hospital to Home for Elders (SHHE) trial. Participants were community-dwelling English, Spanish and Chinese speaking older adults admitted to medicine wards at an urban safety-net hospital in San Francisco. We assessed perceived social support using the Multidimensional Scale of Perceived Social Support (MSPSS). We defined high social support as the highest quartile of MSPSS. We ascertained 30-day readmission and mortality based on a combination of participant self-report, hospital and death records. We used multiple/multivariable logistic regression to adjust for patient demographics, health status, and health behaviors. We tested for whether race/ethnicity modified the effect high social support had on 30-day readmission or death by including a race-social support interaction term. Results Participants ( n  = 674) had mean age of 66.2 (SD 9.0), with 18.8% White, 24.8% Black, 31.9% Asian, and 19.3% Latino. The 30-day readmission or death rate was 15.0%. Those with high social support had half the odds of readmission or death than those with low social support (OR = 0.47, 95% CI 0.26–0.88). Interaction analyses revealed race modified this association; higher social support was protective against readmission or death among minorities (AOR = 0.35, 95% CI 0.16–0.76) but increased likelihood of readmission or death among Whites (AOR = 3.7, 95% CI 1.07–12.9). Conclusion In older safety-net patients nearing discharge, high perceived social support may protect against 30-day readmission or death among minorities. Assessing patients’ social support may aid targeting of transitional care resources and intervention design. How perceived social support functions across racial/ethnic groups in health outcomes warrants further study. Trial registration NIH trials registry number ClinicalTrials.gov: NCT01221532 .

BackgroundSocial connectedness exerts strong influences on health, including major depression and suicide. A major component of social connectedness is having individual relationships with close supports, romantic partners, and other trusted members of one’s social network.ObjectiveThe objective of this study was to understand how individuals’ relationships with close supports might be leveraged to improve outcomes for primary care patients with depression and at risk for suicide.DesignIn this qualitative study, we used a semi-structured interview guide to probe patient experiences, views, and preferences related to social support.ParticipantsWe conducted interviews with 30 primary care patients at a Veterans Health Administration (VA) medical center who had symptoms of major depression and a close support.ApproachThematic analysis of qualitative interview data examined close supports’ impact on patients. We iteratively developed a codebook, used output from codes to sort data into themes, and selected quotations that exemplified themes for inclusion in this manuscript.Key Results“Being there” as an important quality of close supports emerged as a key concept. “Being there” was defined in three ways: physical proximity, frequent or responsive contact, or perceived availability. Close supports who were effective at “being there” possessed skills in intuitively sensing the patient’s emotional state and communicating indirectly about depression. Three major barriers to involving close supports in depression care were concerns of overburdening the close support, a perception that awareness of the patient’s depression would make the close support unnecessarily worried, and a desire and preference among patients to handle depression on their own.Conclusions“Being there” represents a novel, patient-generated way to conceptualize and talk about social support. Suicide prevention initiatives such as population-level communication campaigns might be improved by incorporating language used by patients and addressing attitudinal barriers to allowing help and involvement of close supports.