Eliminating Race-Based Medicine Wright, Joseph L; Davis, Wendy S; Joseph, Madeline M ...
Pediatrics (Evanston),
07/2022, Volume:
150, Issue:
1
Journal Article
Peer reviewed
Race-based medicine has been pervasively interwoven into the fabric of health care delivery in the United States for more than 400 years. Race is a historically derived social construct that has no ...place as a biologic proxy. In addition to valid measures of social determinants of health, the effects of racism require consideration in clinical decision-making tools in ways that are evidence informed and not inappropriately conflated with the limiting phenotype of race categorization. This policy statement addresses the elimination of race-based medicine as part of a broader commitment to dismantle the structural and systemic inequities that lead to racial health disparities.
Objective
Sudden unexpected death in epilepsy (SUDEP) is an important cause of mortality in epilepsy. However, there is a gap in how often providers counsel patients about SUDEP. One potential ...solution is to electronically prompt clinicians to provide counseling via automated detection of risk factors in electronic medical records (EMRs). We evaluated (1) the feasibility and generalizability of using regular expressions to identify risk factors in EMRs and (2) barriers to generalizability.
Methods
Data included physician notes for 3000 patients from one medical center (home) and 1000 from five additional centers (away). Through chart review, we identified three SUDEP risk factors: (1) generalized tonic–clonic seizures, (2) refractory epilepsy, and (3) epilepsy surgery candidacy. Regular expressions of risk factors were manually created with home training data, and performance was evaluated with home test and away test data. Performance was evaluated by sensitivity, positive predictive value, and F‐measure. Generalizability was defined as an absolute decrease in performance by <0.10 for away versus home test data. To evaluate underlying barriers to generalizability, we identified causes of errors seen more often in away data than home data. To demonstrate how small revisions can improve generalizability, we removed three “boilerplate” standard text phrases from away notes and repeated performance.
Results
We observed high performance in home test data (F‐measure range = 0.86‐0.90), and low to high performance in away test data (F‐measure range = 0.53‐0.81). After removing three boilerplate phrases, away performance improved (F‐measure range = 0.79‐0.89) and generalizability was achieved for nearly all measures. The only significant barrier to generalizability was use of boilerplate phrases, causing 104 of 171 errors (61%) in away data.
Significance
Regular expressions are a feasible and probably a generalizable method to identify variables related to SUDEP risk. Our methods may be implemented to create large patient cohorts for research and to generate electronic prompts for SUDEP counseling.
Identifying individuals with rare epilepsy syndromes in electronic data sources is difficult, in part because of missing codes in the International Classification of Diseases (ICD) system. Our ...objectives were the following: (1) to describe the representation of rare epilepsies in other medical vocabularies, to identify gaps; and (2) to compile synonyms and associated terms for rare epilepsies, to facilitate text and natural language processing tools for cohort identification and population-based surveillance. We describe the representation of 33 epilepsies in 3 vocabularies: Orphanet, SNOMED-CT, and UMLS-Metathesaurus. We compiled terms via 2 surveys, correspondence with parent advocates, and review of web resources and standard vocabularies. UMLS-Metathesaurus had entries for all 33 epilepsies, Orphanet 32, and SNOMED-CT 25. The vocabularies had redundancies and missing phenotypes. Emerging epilepsies (
, and
-related epilepsies) were underrepresented. Survey and correspondence respondents included 160 providers, 375 caregivers, and 11 advocacy group leaders. Each epilepsy syndrome had a median of 15 (range 6-28) synonyms. Nineteen had associated terms, with a median of 4 (range 1-41). We conclude that medical vocabularies should fill gaps in representation of rare epilepsies to improve their value for epilepsy research. We encourage epilepsy researchers to use this resource to develop tools to identify individuals with rare epilepsies in electronic data sources.
To test the hypotheses that minority children with long-bone fractures are less likely to (1) receive analgesics, (2) receive opioid analgesics, and (3) achieve pain reduction.
We performed a 3-year ...retrospective cross-sectional study of children <18 years old with long-bone fractures using the Pediatric Emergency Care Applied Research Network Registry (7 emergency departments). We performed bivariable and multivariable logistic regression to measure the association between patient race and ethnicity and (1) any analgesic, (2) opioid analgesic, (3) ≥2-point pain score reduction, and (4) optimal pain reduction (ie, to mild or no pain).
In 21 069 visits with moderate-to-severe pain, 86.1% received an analgesic and 45.4% received opioids. Of 8533 patients with reassessment of pain, 89.2% experienced ≥2-point reduction in pain score and 62.2% experienced optimal pain reduction. In multivariable analyses, minority children, compared with non-Hispanic (NH) white children, were more likely to receive any analgesics (NH African American: adjusted odds ratio aOR 1.72 95% confidence interval 1.51-1.95; Hispanic: 1.32 1.16-1.51) and achieve ≥2-point reduction in pain (NH African American: 1.42 1.14-1.76; Hispanic: 1.38 1.04-1.83) but were less likely to receive opioids (NH African American: aOR 0.86 0.77-0.95; Hispanic: aOR 0.86 0.76-0.96) or achieve optimal pain reduction (NH African American: aOR 0.78 0.67-0.90; Hispanic: aOR 0.80 0.67-0.95).
There are differences in process and outcome measures by race and ethnicity in the emergency department management of pain among children with long-bone fractures. Although minority children are more likely to receive analgesics and achieve ≥2-point reduction in pain, they are less likely to receive opioids and achieve optimal pain reduction.
Objective
The aim of this study is to elucidate the unique challenges faced by pediatric emergency medicine (PEM) physicians from racial/ethnic groups underrepresented in medicine (URiM).
Methods
...This study is a subanalysis of data from 18 URiM faculty from a sample of 51 semistructured key informant interviews with PEM faculty in the top NIH‐funded pediatric departments and highest‐volume pediatric EDs in the country. Faculty are from eight hospitals representing a spectrum of geographic locations including the northeastern, midwestern, western, and southern regions of the country.
Results
Of 18 study participants, the majority were Black (72.2%) and female (83.3%). Three main thematic categories were identified: challenges related to race, support systems, and suggested strategies to improve diversity and inclusion in PEM. A common race‐related experience was microaggressions from colleagues and patients. Additionally, when attempting to lead and assert themselves, URiM women in particular were perceived as “angry” and “intimidating” in a way that non‐URiM peers were not. As a result of these negative experiences, participants described the need to go above and beyond to prove themselves. Such pressure produced stress and feelings of isolation. Participants combatted these stressors through resilience strategies such as formal mentorship and peer and family support. Participants indicated the need to increase diversity and create more inclusive work environments, which would benefit both URiM physician wellness and the diverse patients they serve.
Conclusion
Those URiM in PEM face subtle racial discrimination at an institutional, peer, and patient level. The stress caused by this discrimination may further contribute to physician burnout in PEM. While URiMs adopt individual resilience strategies, their unique challenges suggest the need for departmental and institutional efforts to promote greater diversity and inclusion for physician wellness, retention, and quality patient care.
The last several years have seen accelerated activity and discourse directed at antiracism. Specifically following the 2020 murder of George Floyd, institutions across the country engaged in a range ...of introspective exercises and transparent reckonings examining their practices, policies, and history insofar as equity and racism is concerned. The authors of this article, both active protagonists in this domain, have been, and continue to be, part of ongoing national efforts and have learned much about the strategies and tactics necessary to initiate, engage, and sustain traction on the path to antiracism.
To determine if race/ethnicity-based differences exist in the management of pediatric abdominal pain in emergency departments (EDs).
Secondary analysis of data from the 2006-2009 National Hospital ...Ambulatory Medical Care Survey regarding 2298 visits by patients ≤ 21 years old who presented to EDs with abdominal pain. Main outcomes were documentation of pain score and receipt of any analgesics, analgesics for severe pain (defined as ≥ 7 on a 10-point scale), and narcotic analgesics. Secondary outcomes included diagnostic tests obtained, length of stay (LOS), 72-hour return visits, and admission.
Of patient visits, 70.1% were female, 52.6% were from non-Hispanic white, 23.5% were from non-Hispanic black, 20.6% were from Hispanic, and 3.3% were from "other" racial/ethnic groups; patients' mean age was 14.5 years. Multivariate logistic regression models adjusting for confounders revealed that non-Hispanic black patients were less likely to receive any analgesic (odds ratio OR: 0.61; 95% confidence interval CI: 0.43-0.87) or a narcotic analgesic (OR: 0.38; 95% CI: 0.18-0.81) than non-Hispanic white patients (referent group). This finding was also true for non-Hispanic black and "other" race/ethnicity patients with severe pain (ORs 95% CI: 0.43 0.22-0.87 and 0.02 0.00-0.19, respectively). Non-Hispanic black and Hispanic patients were more likely to have a prolonged LOS than non-Hispanic white patients (ORs 95% CI: 1.68 1.13-2.51 and 1.64 1.09-2.47, respectively). No significant race/ethnicity-based disparities were identified in documentation of pain score, use of diagnostic procedures, 72-hour return visits, or hospital admissions.
Race/ethnicity-based disparities exist in ED analgesic use and LOS for pediatric abdominal pain. Recognizing these disparities may help investigators eliminate inequalities in care.
The objective of this study was to determine the attitudes, skill level, and preferred educational interventions of pediatric residents related to implicit bias and caring for diverse patient ...populations. A cross-sectional survey of pediatric residents at a single, large urban residency program was utilized. Surveys were completed by 88 (55%) residents who were 69% female and 35% non-White or mixed race. Almost all residents felt that it was very or extremely important to receive training on health disparities, diverse patient populations, and implicit bias. Self-assessment of skill level revealed that residents felt confident in areas often covered by cultural competency curricula, such as interpreter use, but were less confident in other areas. The top 3 areas identified for further training included implicit bias, working with transgender and gender nonconforming patients, and weight bias. For the majority of diversity and bias-related skills, prior training was significantly correlated with higher skill level (P < .05).
PDF
