Leslie Wright

Clinicians’ Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients

PURPOSE We investigated whether clinicians’ explicit and implicit ethnic/racial bias is related to black and Latino patients’ perceptions of their care in established clinical relationships. METHODS We administered a telephone survey to 2,908 patients, stratified by ethnicity/race, and randomly selected from the patient panels of 134 clinicians who had previously completed tests of explicit and implicit ethnic/racial bias. Patients completed the Primary Care Assessment Survey, which addressed their clinicians’ interpersonal treatment, communication, trust, and contextual knowledge. We created a composite measure of patient-centered care from the 4 subscales. RESULTS Levels of explicit bias were low among clinicians and unrelated to patients’ perceptions. Levels of implicit bias varied among clinicians, and those with greater implicit bias were rated lower in patient-centered care by their black patients as compared with a reference group of white patients (P = .04). Latino patients gave the clinicians lower ratings than did other groups (P <.0001), and this did not depend on the clinicians’ implicit bias (P = .98). CONCLUSIONS This is among the first studies to investigate clinicians’ implicit bias and communication processes in ongoing clinical relationships. Our findings suggest that clinicians’ implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes. As such, this finding supports the Institute of Medicine’s suggestion that clinician bias may contribute to health disparities. Latinos’ overall greater concerns about their clinicians appear to be based on aspects of care other than clinician bias.

Patient-Identified Factors Related to Heart Failure Readmissions

Background—Although readmission after hospitalization for heart failure has received increasing attention, little is known about its root causes. Prior investigations have relied on administrative databases, chart review, and single-question surveys. Methods and Results—We performed semistructured 30- to 60-minute interviews of patients (n=28) readmitted within 6 months of index heart failure admission. Established qualitative approaches were used to analyze and to interpret data. Interview findings were the primary focus of the study, but patient information and provider comments from chart data were also consulted. Patient median age was 61 years; 29% were nonwhite; 50% were married; 32% had preserved ejection fraction; and median time from discharge to readmission was 31 days. Reasons for readmission were multifactorial and not easily categorized into mutually exclusive reasons. Five themes emerged as reasons cited for hospital readmission: distressing symptoms, unavoidable progression of illness, influence of psychosocial factors, good but imperfect self-care adherence, and health system failures. Conclusions—Our study provides the first systematic qualitative assessment of patient perspectives concerning heart failure readmission. Contrary to prior literature and distinct from what we found documented in the medical record, patient experiences were highly heterogeneous, not easily categorized as preventable or not preventable, and not easily attributed to a single cause. These findings suggest that future interventions designed to reduce heart failure readmissions should be multifaceted, should be systemic in nature, and should integrate patient input.

Assessing Capacity for Providing Culturally Competent Services to LGBT Older Adults

This qualitative, interview-based study assessed the cultural competence of health and social service providers to meet the needs of LGBT older adults in an urban neighborhood in Denver, Colorado, known to have a large LGBT community. Only 4 of the agencies were categorized as “high competency”; 12 were felt to be “seeking improvement” and 8 were considered “not aware.” These results indicate significant gaps in cultural competency for the majority of service providers. Social workers are well-suited to lead efforts directed at improving service provision and care competencies for the older LGBT community.

Increasingly restrictive definitions of hyperkalemia outcomes in a database study: effect on incidence estimates.

To determine the incidence of hyperkalemia‐associated adverse outcomes among ambulatory patients with diabetes newly initiating renin‐angiotensin‐aldosterone system (RAAS) inhibitor therapy and to examine to what extent increasingly restrictive definitions of hyperkalemia‐associated outcomes influenced incidence estimates.

The Positive Predictive Value of a Hyperkalemia Diagnosis in Automated Health Care Data

Our objectives were to determine performance of coded hyperkalemia diagnosis at identifying (1) clinically evident hyperkalemia and (2) serum potassium>6 mmol/L.

Perspectives of LGBTQ Older Adults on Aging in Place: A Qualitative Investigation

ABSTRACT This qualitative study conducted by a community-research partnership used multiple types of data collection to examine variables relevant for LGBTQ older adults who wished to age in place in their urban Denver neighborhood. Focus groups, interviews, and a town hall meeting were used to identify barriers and supports to aging in place. Participants (N = 73) identified primarily as lesbian or gay, aged 50–69, and lived with a partner. Ageism, heterosexism, and cisgenderism emerged as cross-cutting themes that negatively impact access to health care, housing, social support, home assistance, and legal services. Resilience from weathering a lifetime of discrimination was identified as a strength to handle aging challenges. Recommendations for establishing an aging in place model included establishing welcoming communities and resource centers and increasing cultural competence of service providers. This study provides a unique contribution to understanding the psychosocial, medical, and legal barriers for successfully aging in place.

Lessons learned from community-based participatory research: establishing a partnership to support lesbian, gay, bisexual and transgender ageing in place

Background Due to a history of oppression and lack of culturally competent services, lesbian, gay, bisexual and transgender (LGBT) seniors experience barriers to accessing social services. Tailoring an evidence-based ageing in place intervention to address the unique needs of LGBT seniors may decrease the isolation often faced by this population. Objective To describe practices used in the formation of a community-based participatory research (CBPR), partnership involving social workers, health services providers, researchers and community members who engaged to establish a LGBT ageing in place model called Seniors Using Supports To Age In Neighborhoods (SUSTAIN). Methods A case study approach was employed to describe the partnership development process by reflecting on past meeting minutes, progress reports and interviews with SUSTAINs partners. Results Key partnering practices utilized by SUSTAIN included (i) development of a shared commitment and vision; (ii) identifying partners with intersecting spheres of influence in multiple communities of identity (ageing services, LGBT, health research); (iii) attending to power dynamics (e.g. equitable sharing of funds); and (iv) building community capacity through reciprocal learning. Although the partnership dissolved after 4 years, it served as a successful catalyst to establish community programming to support ageing in place for LGBT seniors. Conclusion Multi-sector stakeholder involvement with capacity to connect communities and use frameworks that formalize equity was key to establishing a high-trust CBPR partnership. However, lack of focus on external forces impacting each partner (e.g. individual organizational strategic planning, community funding agency perspectives) ultimately led to dissolution of the SUSTAIN partnership even though implementation of community programming was realized.

C-C3-02: Increasingly Restrictive Definitions of Hyperkalemia Outcomes in a Database Study: Effect on Incidence Estimates.

Background/Aims: Determination of hyperkalemia associated adverse outcomes incidence and risk assessment is complicated by lack of consistent hyperkalemia definitions across studies. Further, information about hyperkalemia from clinical trials, while reflecting the potential of renin-angiotensin-aldosterone system (RAAS) inhibitor treatment to increase serum potassium (K) concentration above a defined level, may not reflect risk or severity of outcomes. We sought to examine to what extent increasing levels of restriction influenced incidence estimates of hyperkalemia outcomes. Methods: The study cohort was drawn from a population of adult patients with diabetes at 3 HMORN sites. We identified all new users of a RAAS inhibitor between 01/01/2001 and 12/31/2006 and assessed hyperkalemia-associated outcomes within the first year of therapy. The initial definition of a hyperkalemia outcome to which other definitions were compared included any ambulatory (AV), emergency department (ED) or inpatient (IP) visit with a K level > 5.5 mmol/l or a coded hyperkalemia diagnosis within 7 days of the visit. The following restrictions were then applied: increasing minimum K concentration to > 6.0 mmol/l; reducing timeframe to 24 hours; and removing AV. Crude incidence rates of hyperkalemia-associated adverse outcomes were calculated using person years (p-y) determined as time from drug initiation to first outcome or other censoring event (e.g., drug discontinuation, end of study). Results: The cohort included 27,362 patients. Mean duration of initial therapy was 212 days. Hyperkalemia-associated outcome incidence estimates varied from 33.6 per 1000 p-y (defined as AV, ED or IP visit with K > 5.5 or a coded hyperkalemia diagnosis within 7 days) to 11.0 per 1000 p-y (defined as IP or ED visit with K > 6 or coded diagnosis within 24 hours). Removing AV had the greatest effect and reducing the timeframe to 24 hours had the least effect on incidence estimates. Conclusions: Modifying hyperkalemia definition criteria resulted in up to a 3-fold difference in by estimates of hyperkalemia-associated adverse outcomes. Further work linking these findings to adverse events is critical to decisions regarding appropriate definitions to answer specific study questions. We caution against comparing incidence estimates across published studies without considering the severity implications of differences in hyperkalemia outcomes definitions.