Intersection of Structural Racism, Social Determinants of Health, and Implicit Bias With Emergency Physician Admission Tendencies

Egede, Leonard E.; Walker, Rebekah J.; Williams, Joni S.

doi:10.1001/jamanetworkopen.2021.26375

Cited by 12 publications

(15 citation statements)

References 10 publications

(30 reference statements)

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“…16,46,47 However, this is one of the first studies to suggest that low income can contribute to implicit bias. 47 Since income status may not be readily apparent to clinicians, further investigation is needed to better understand whether specific patient attributes or behaviors contribute to the suspected implicit bias observed among adults with low income. This phenomenon could relate to clinician perceptions about treatment adherence and/or affordability of services for adults with low income but will require further investigation.…”

Section: Discussionmentioning

confidence: 92%

Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure

Zhang

Onyebeke

Nahid

et al. 2023

Preprint

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Background: The involvement of a cardiologist in the care of adults during a hospitalization for heart failure (HF) is associated with reduced mortality and readmission rates. However, not all patients see a cardiologist when hospitalized for HF. Since reasons remain unclear, we sought to determine whether social determinants of health (SDOH) are associated with cardiologist involvement. Methods: We included adult participants from the national REasons for Geographic And Racial Difference in Stroke (REGARDS) cohort, who experienced an adjudicated hospitalization for HF from 2009-2017. We excluded participants who were hospitalized at institutions that lacked cardiology services (n=246). We examined nine candidate SDOH: Black race, social isolation, social network, educational attainment, annual household income, living in rural areas, living in a zip code with high poverty, living in a Health Professional Shortage Area, and residing in a state with poor public health infrastructure. The primary outcome was cardiologist involvement. We examined associations between each SDOH and cardiologist involvement using Poisson regression with robust standard errors. Candidate SDOH with significant associations were retained for multivariable analysis. Covariates included age, race, sex, HF characteristics, comorbidities, and hospital characteristics. Results: We examined 876 participants hospitalized at 549 unique US hospitals. The median age was 77.5 years, 45.9% were female, 41.4% were Black, and 56.2% had low income. Low household income (<$35,000/year) was the only SDOH significantly associated with cardiologist involvement. After adjusting for potential confounders, low income remained inversely associated (RR: 0.89 [95% CI: 0.82-0.97]). Conclusions: Adults with low household income were 11% less likely to have a cardiologist involved in their care during a hospitalization for HF. This suggests that socioeconomic status may implicitly bias their care.

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Section: Discussionmentioning

confidence: 92%

Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure

Zhang

Onyebeke

Nahid

et al. 2023

Preprint

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“…In the context of this study, it was found that neighborhood SEP did not mediate the associations of race and ethnicity with survival, but it had its own association. This reflects a far more complex social reality than is often presented in health services research …”

Section: Discussionmentioning

confidence: 98%

Association of Socioeconomic Position With Racial and Ethnic Disparities in Survival After Lung Transplant

et al. 2023

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ImportanceA recent National Academies of Sciences, Engineering, and Medicine study found that transplant outcomes varied greatly based on multiple factors, including race, ethnicity, and geographic location. They proposed a number of recommendations including studying opportunities to improve equity in organ allocation.ObjectiveTo evaluate the role of donor and recipient socioeconomic position and region as a mediator of observed racial and ethnic differences in posttransplant survival.Design, Setting, and ParticipantsThis cohort study included lung transplant donors and recipients with race and ethnicity information and a zip code tabulation area–defined area deprivation index (ADI) from September 1, 2011, to September 1, 2021, whose data were in the US transplant registry. Data were analyzed from June to December 2022.ExposuresRace, neighborhood disadvantage, and region of donors and recipients.Main Outcomes and MeasuresUnivariable and multivariable Cox proportional hazards regression were used to study the association of donor and recipient race with ADI on posttransplant survival. Kaplan-Meier method estimation was performed by donor and recipient ADI. Generalized linear models by race were fit, and mediation analysis was performed. Bayesian conditional autoregressive Poisson rate models (1, state-level spatial random effects; 2, model 1 with fixed effects for race and ethnicity, 3; model 2 excluding region; and 4: model 1 with fixed effects for US region) were used to characterize variation in posttransplant mortality and compared using ratios of mortality rates to the national average.ResultsOverall, 19 504 lung transplant donors (median [IQR] age, 33 [23-46] years; 3117 [16.0%] Hispanic individuals, 3667 [18.8%] non-Hispanic Black individuals, and 11 935 [61.2%] non-Hispanic White individuals) and recipients (median [IQR] age, 60 [51-66] years; 1716 [8.8%] Hispanic individuals, 1861 [9.5%] non-Hispanic Black individuals, and 15 375 [78.8%] non-Hispanic White individuals) were included. ADI did not mediate the difference in posttransplant survival between non-Hispanic Black and non-Hispanic White recipients; it mediated only 4.1% of the survival difference between non-Hispanic Black and Hispanic recipients. Spatial analysis revealed the increased risk of posttransplant death among non-Hispanic Black recipients may be associated with region of residence.Conclusions and RelevanceIn this cohort study of lung transplant donors and recipients, socioeconomic position and region of residence did not explain most of the difference in posttransplant outcomes among racial and ethnic groups, which may be due to the highly selected nature of the pretransplant population. Further research should evaluate other potentially mediating effects contributing to inequity in posttransplant survival.

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“…Black/African Americans are less likely to receive referrals to specialists, particularly for cardiovascular care, and implicit bias among physicians leads to poor communication, lack of identification of disease symptoms, and missed diagnoses ( 5 , 64 – 67 ). Despite the recent focus on cultural racism and implicit bias ( 68 ), many physicians deny the existence and impact of cultural racism on the delivery of health care and health care outcomes ( 69 ).…”

Section: Pathways: Impact Of Racism and Discrimination On Cardiovascu...mentioning

confidence: 99%

Impact of Federal, State, and Local Housing Policies on Disparities in Cardiovascular Disease in Black/African American Men and Women: From Policy to Pathways to Biology

Sistrunk

Tolbert

Sanchez-Pino

et al. 2022

Front. Cardiovasc. Med.

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Racist and discriminatory federal, state, and local housing policies significantly contribute to disparities in cardiovascular disease incidence and mortality for individuals that self-identify as Black or African American. Here we highlight three key housing policies – “redlining,” zoning, and the construction of highways – which have wrought a powerful, sustained, and destructive impact on cardiovascular health in Black/African American communities. Redlining and highway construction policies have restricted access to quality health care, increased exposure to carcinogens such as PM2.5, and increased exposure to extreme heat. At the root of these policy decisions are longstanding, toxic societal factors including racism, segregation, and discrimination, which also serve to perpetuate racial inequities in cardiovascular health. Here, we review these societal and structural factors and then link them with biological processes such as telomere shortening, allostatic load, oxidative stress, and tissue inflammation. Lastly, we focus on the impact of inflammation on the immune system and the molecular mechanisms by which the inflamed immune microenvironment promotes the formation of atherosclerotic plaques. We propose that racial residential segregation and discrimination increases tissue inflammation and cytokine production, resulting in dysregulated immune signaling, which promotes plaque formation and cardiovascular disease. This framework has the power to link structural racism not only to cardiovascular disease, but also to cancer.

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Intersection of Structural Racism, Social Determinants of Health, and Implicit Bias With Emergency Physician Admission Tendencies

Cited by 12 publications

References 10 publications

Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure

Social Determinants of Health and Cardiologist Involvement in the Care of Adults Hospitalized for Heart Failure

Association of Socioeconomic Position With Racial and Ethnic Disparities in Survival After Lung Transplant

Impact of Federal, State, and Local Housing Policies on Disparities in Cardiovascular Disease in Black/African American Men and Women: From Policy to Pathways to Biology

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