Rebecca Hanratty

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.

Left ventricular hypertrophy and cardiovascular mortality by race and ethnicity.

BACKGROUND Left ventricular hypertrophy is a major independent risk factor for cardiovascular mortality. The contribution of left ventricular hypertrophy to racial and ethnic differences in cardiovascular mortality is poorly understood. METHODS We used data from the Third National Health and Nutrition Examination Survey and from the National Death Index to compare mortality for those with an electrocardiographic (ECG) diagnosis of left ventricular hypertrophy to those without left ventricular hypertrophy separately for whites, African Americans, and Latinos. We used Cox proportional hazards regression to control for other known prognostic factors. RESULTS ECG left ventricular hypertrophy was significantly associated with 10-year cardiovascular mortality in all 3 racial/ethnic groups, both unadjusted and adjusted for other known prognostic factors. The hazard ratio for this association was significantly greater for African Americans (2.31; 95% confidence interval [CI], 1.55-3.42) than for whites and Latinos (1.32; 95% CI, 1.14-1.76 and 2.11; 95% CI, 1.35-3.30, respectively), independent of systolic blood pressure. CONCLUSIONS ECG left ventricular hypertrophy contributes more to the risk of cardiovascular mortality in African Americans than it does in whites. Using regression of ECG left ventricular hypertrophy as a goal of therapy might be a means to reduce racial differences in cardiovascular mortality; prospective validation is required.

Sociodemographic and Clinical Characteristics Are Not Clinically Useful Predictors of Refill Adherence in Patients With Hypertension

Background—Although many studies have identified patient characteristics or chronic diseases associated with medication adherence, the clinical utility of such predictors has rarely been assessed. We attempted to develop clinical prediction rules for adherence with antihypertensive medications in 2 healthcare delivery systems. Methods and Results—We performed retrospective cohort studies of hypertension registries in an inner-city healthcare delivery system (n=17 176) and a health maintenance organization (n=94 297) in Denver, Colo. Adherence was defined by acquisition of 80% or more of antihypertensive medications. A multivariable model in the inner-city system found that adherent patients (36.3% of the total) were more likely than nonadherent patients to be older, white, married, and acculturated in US society, to have diabetes or cerebrovascular disease, not to abuse alcohol or controlled substances, and to be prescribed fewer than 3 antihypertensive medications. Although statistically significant, all multivariate odds ratios were 1.7 or less, and the model did not accurately discriminate adherent from nonadherent patients (C statistic=0.606). In the health maintenance organization, where 72.1% of patients were adherent, significant but weak associations existed between adherence and older age, white race, the lack of alcohol abuse, and fewer antihypertensive medications. The multivariate model again failed to accurately discriminate adherent from nonadherent individuals (C statistic=0.576). Conclusions—Although certain sociodemographic characteristics or clinical diagnoses are statistically associated with adherence to refills of antihypertensive medications, a combination of these characteristics is not sufficiently accurate to allow clinicians to predict whether their patients will be adherent with treatment.

Thresholds in the Relationship between Mortality and Left Ventricular Hypertrophy Defined by Electrocardiography

BACKGROUND Electrocardiographic criteria for the diagnosis of left ventricular hypertrophy in current use were defined using autopsy results or echocardiography; criteria defined using mortality might be more clinically meaningful. METHODS Using data from Third National Health and Nutrition Examination Survey (NHANES III), we selected electrocardiographic measures that best differentiated those surviving at 5 years from those who did not. We identified voltage thresholds using regression techniques and then compared survival for subjects above and below the thresholds. RESULTS Cornell voltage, Cornell product, and Novacode estimate of left ventricular mass index were discriminative for mortality and had identifiable thresholds present in their relationships with mortality. Independent of systolic blood pressure, there were significant associations with 5-year mortality for Novacode index above threshold; hazard ratios were 1.58 for women and 1.27 for men, and for 5-year cardiovascular mortality were 1.78 for women and 2.34 for men. CONCLUSIONS Electrocardiographic criteria for left ventricular hypertrophy validated against mortality might be clinically useful.

Incident chronic kidney disease and the rate of kidney function decline in individuals with hypertension

Background. Little is known about the decline of kidney function in patients with normal kidney function at baseline. Our objectives were to (i) identify predictors of incident chronic kidney disease (CKD) and (ii) to estimate rate of decline in kidney function. Methods. The study used a retrospective cohort of adult patients in a hypertension registry in an inner-city health care delivery system in Denver, Colorado. The primary outcome was development of incident CKD, and the secondary outcome was rate of change of estimated glomerular filtration rate (eGFR) over time. Results. After a mean follow-up of 45 months, 429 (4.1%) of 10 420 patients with hypertension developed CKD. In multivariate models, factors that independently predicted incident CKD were baseline age [odds ratio (OR) 1.13 per 10 years, 95% confidence interval (CI), 1.03–1.24], baseline eGFR (OR 0.69 per 10 units, 95% CI 0.65–0.73), diabetes (OR 3.66, 95% CI 2.97–4.51) and vascular disease (OR 1.67, 95% CI 1.32–2.10). We found no independent association between age, gender or race/ethnicity and eGFR slope. In patients who did not have diabetes or vascular disease, eGFR declined at 1.5 mL/min/1.73 m2 per year. Diabetes at baseline was associated with an additional decline of 1.38 mL/min/1.73 m2. Conclusions. Diabetes was the strongest predictor of both incident CKD as well as eGFR slope. Rates of incident CKD or in decline of kidney function did not differ by race or ethnicity in this cohort.

Testing electronic algorithms to create disease registries in a safety net system.

Electronic disease registries are a critical feature of the chronic disease management programs that are used to improve the care of individuals with chronic illnesses. These registries have been developed primarily in managed care settings; use in safety net institutions—organizations whose mission is to serve the uninsured and underserved—has not been described. We sought to assess the feasibility of developing disease registries from electronic data in a safety net institution, focusing on hypertension because of its importance in minority populations. We compared diagnoses obtained from algorithms utilizing electronic data, including laboratory and pharmacy records, against diagnoses derived from chart review. We found good concordance between diagnoses identified from electronic data and those identified by chart review, suggesting that registries of patients with chronic diseases can be developed outside the setting of closed panel managed care organizations.

Simultaneous Control of Diabetes Mellitus, Hypertension, and Hyperlipidemia in 2 Health Systems

Background—Many individuals with diabetes mellitus, hypertension, and hyperlipidemia have difficulty achieving control of all 3 conditions. We assessed the incidence and duration of simultaneous control of hyperglycemia, blood pressure, and low-density lipoprotein cholesterol in patients from 2 health care systems in Colorado. Methods and Results—We performed a retrospective cohort study of adults at Denver Health and Kaiser Permanente Colorado with diabetes mellitus, hypertension, and hyperlipidemia from 2000 through 2008. Over a median of 4.0 and 4.4 years, 16% and 30% of individuals at Denver Health and Kaiser Permanente achieved the primary outcome (simultaneous control with a glycosylated hemoglobin (HbA1c) <7.0%, blood pressure <130/80 mm Hg, and low-density lipoprotein cholesterol <100 mg/dL), respectively. With less strict goals (HbA1c <8.0%, blood pressure <140/90 mm Hg, and low-density lipoprotein cholesterol <130 mg/dL), 44% and 70% of individuals at Denver Health and Kaiser Permanente achieved simultaneous control. Sociodemographic characteristics (increasing age, white ethnicity), and the presence of cardiovascular disease or other comorbidities were significantly but not strongly predictive of achieving simultaneous control in multivariable models. Simultaneous control was less likely as severity of the underlying conditions increased, and more likely as medication adherence increased. Conclusions—Simultaneous control of diabetes mellitus, hypertension, and hyperlipidemia was uncommon and generally transient. Less stringent goals had a relatively large effect on the proportion achieving simultaneous control. Individuals who simultaneously achieve multiple treatment goals may provide insight into self-care strategies for individuals with comorbid health conditions.