An Investigation of Associations Between Clinicians’ Ethnic or Racial Bias and Hypertension Treatment, Medication Adherence and Blood Pressure Control

Abstract

BACKGROUND: Few studies have directly investigated the association of clinicians' implicit (unconscious) bias with health care disparities in clinical settings. OBJECTIVE: To determine if clinicians' implicit ethnic or racial bias is associated with processes and outcomes of treatment for hypertension among black and Latino patients, relative to white patients. RESEARCH DESIGN AND PARTICIPANTS: Primary care clinicians completed Implicit Association Tests of ethnic and racial bias. Electronic medical records were queried for a stratified, random sample of the clinicians' black, Latino and white patients to assess treatment intensification, adherence and control of hypertension. Multilevel random coefficient models assessed the associations between clinicians' implicit biases and ethnic or racial differences in hypertension care and outcomes. MAIN MEASURES: Standard measures of treatment intensification and medication adherence were calculated from pharmacy refills. Hypertension control was assessed by the percentage of time that patients met blood pressure goals recorded during primary care visits. KEY RESULTS: One hundred and thirty-eight primary care clinicians and 4,794 patients with hypertension participated. Black patients received equivalent treatment intensification, but had lower medication adherence and worse hypertension control than white patients; Latino patients received equivalent treatment intensification and had similar hypertension control, but lower medication adherence than white patients. Differences in treatment intensification, medication adherence and hypertension control were unrelated to clinician implicit bias for black patients (P=0.85, P= 0.06 and P=0.31, respectively) and for Latino patients (P=0.55, P=0.40 and P=0.79, respectively). An increase in clinician bias from average to strong was associated with a relative change of less than 5 % in all outcomes for black and Latino patients. CONCLUSIONS: Implicit bias did not affect clinicians' provision of care to their minority patients, nor did it affect the patients' outcomes. The identification of health care contexts in which bias does not impact outcomes can assist both patients and clinicians in their efforts to build trust and partnership.KEY WORDS: hypertension; healthcare disparities; discrimination; implicit bias; race/ethnicity; quality. J Gen Intern Med 29(7):987-95

What you can't see can hurt you: How do stereotyping, implicit bias and stereotype threat affect Māori health?

“…Thus, while implicit bias may not lead to overt discrimination, when the provider and the patient come from different cultural or racial groups, health providers may be less effective at establishing a good rapport with their clients (Blair et al, 2014). Dovidio, Kawakami and Gaertner (2002) have shown that implicit attitudes "leak" during interactions through the display of negative non-verbal behaviours, meaning that those with higher implicit biases may be perceived as less friendly by out-group minorities.…”

Leading the Way in Health Disparities Research

“…Annals of Internal Medicine published just 29 articles over this same time period). While as a society we have not come close to former Surgeon General Dr. David Satcher's call to eliminate health disparities by the year 2010, JGIM has continued to shine a light on this shameful national tragedy by featuring high-quality original research that not only underscores the impact of racial and ethnic disparities, but also has broadened the scope of research on health disparities to include discrimination against persons with certain diseases such as sickle cell anemia 1 , discrimination against sexual minorities 2 , and groundbreaking work on the insidious influence of unconscious bias on health care delivery 3 .…”

Unconscious Bias and Real-World Hypertension Outcomes: Advancing Disparities Research

“…Many of these studies were conducted by measuring physicians' level of implicit bias against racial/ethnic minorities using the well-validated Implicit Associations Test (IAT), 2 and then linking the level of bias to provider behavior or decision making in clinical simulations, scenarios and vignettes. 3 However, when observing how a physician behaves or responds to a hypothetical vignette or scenario, it is not physician behavior that is being measured; rather, it is the physician's behavioral intention in the given scenario or vignette, which is not always predictive of actual behavior. Thus, more research that examines physicians' unconscious bias in the context of their actual behavior (with actual patients) is needed.…”

“…3 In a well-designed study, the authors administered IATs to 138 primary care physicians across two health systems in Colorado. Next, via electronic medical record review, hypertension-related process and clinical outcomes of 4,794 Black, Latino and white patients cared for by the 138 participating physicians were examined and modeled for associations with physician biases.…”

“…These features include the opportunity for strong working relationships between patients and physicians; opportunities afforded by the longitudinal nature of primary care to address the patients' medical needs in ways that avoid the influence of bias; strong expectations for meeting hypertension control guidelines at the organizaPublished online April 8, 2014 tional level; and lastly, checks and balances that occur in primary care teams (e.g., physicians, nurses and pharmacists), and in integrated health care systems. 3 Such structural 'safeguards' may be important for minimizing the potential negative impact of physician bias.…”