Racial and Ethnic Differences in Psychiatry Resident Prescribing: a Quality Improvement Education Intervention to Address Health Equity

Abstract

Objective Quality improvement (QI) tools can identify and address health disparities. This paper describes the use of resident prescriber profiles in a novel QI curriculum to identify racial and ethnic differences in antidepressant and antipsychotic prescribing. Methods The authors extracted medication orders written by 111 psychiatry residents over an 18-month period from an electronic medical record and reformatted these into 6133 unique patient encounters. Binomial logistic models adjusted for covariates assessed racial and ethnic differences in antipsychotic or antidepressant prescribing in both emergency and inpatient psychiatric encounters. A multinomial model adjusted for covariates then assessed racial and ethnic differences in primary diagnosis. Models also examined interactions between gender and race/ethnicity. Results Black (adjusted OR 0.66; 95% CI, 0.50-0.87; p < 0.01) and Latinx (adjusted OR, 0.65; 95% CI, 0.49-0.86; p < 0.01) patients had lower odds of receiving antidepressants relative to White patients despite diagnosis. Black and Latinx patients were no more likely to receive antipsychotics than White patients when adjusted for diagnosis. Black (adjusted OR 3.85; 95% CI, 2.9-5.2) and Latinx (adjusted OR 1.60; 95% CI, 1.1-2.3) patients were more likely to receive a psychosis than a depression diagnosis when compared to White patients. Gender interactions with race/ethnicity did not significantly change results. Conclusions Our findings suggest that racial/ethnic differences in antidepressant prescription likely result from alternatively higher diagnosis of psychotic disorders and prescription of antipsychotics in Black and Latinx patients. Prescriber profiles can serve as a powerful tool to promote resident QI learning around the effects of structural racism on clinical care.

Uses of Electronic Health Record Data to Measure the Clinical Learning Environment of Graduate Medical Education Trainees: A Systematic Review

“…Two articles are of note within the professionalism competency, which we hope herald an emerging trend in medical education research. The pioneering study by Cerdeña et al 41 of trainee prescribing practices by patient ethnicity is noteworthy in light of the ACGME Equity Matters initiative 98 and increasing commitment to antiracism in GME. The findings of a correlation of EHR use logs with physician well-being in the study by Mosquera et al 68 demonstrate that reliable proxies for well-being may be automatically measured through the EHR.…”

“…[35][36][37][40][41][42][43]45,48,51 Five of 17 articles (29%) paired this feedback with attending coaching to focus learning and catalyze improvement efforts. 36,37,41,43,51 The systems-based practice competency Systems-based practice entails the "awareness of and responsiveness to the larger context and system of health care … as well as the ability to call effectively on other resources to provide optimal health care. " 1 Thirteen articles (15%) clustered within this competency, covering 2 themes: continuity of care (12 articles) and panel size (1 article).…”

“…Percentage of visits in continuity clinic with patients for whom the trainee is the designated primary care practitioner 56 Panel size 63 1 (1) Number of patients assigned to a trainee in a specific role (e.g., primary care practitioner) Number of patients in primary care panel 63 Medical knowledge 32,49,64,65 4 (5) "Knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care" 1 Test scores on in-training exam compared with clinical volume 64 Accountability to patients 57,66,67 3 (3) Trainee behaviors demonstrating accountability to patients for whom they have a therapeutic relationship Trainee direct visualization of radiology studies performed on their inpatients 67 Equity of care 41 1 (1) Trainee practice examined along equity lines Trainee psychiatric management of a given condition, stratified by patient ethnicity 41 Physician well-being 68 [6][7][8]11,[14][15][16][20][21][22] Current Procedural Terminology codes, 6,7 chief concern, 6,12,13 or discharge diagnosis. 19 Most authors created bespoke mappings of raw EHR data to educationally meaningful groupings (16 of 17 [94%]).…”

“…[49][50][51] Following collection of trainee data, 10 of 17 articles (59%) fed individual practice data back to trainees through reports or dashboards to facilitate PBLI. [35][36][37][40][41][42][43]45,48,51 Five of 17 articles (29%) paired this feedback with attending coaching to focus learning and catalyze improvement efforts. 36,37,41,43,51 The systems-based practice competency Systems-based practice entails the "awareness of and responsiveness to the larger context and system of health care … as well as the ability to call effectively on other resources to provide optimal health care. "…”

“…67 Equitable care was explored among psychiatry trainees in terms of prescribing patterns by patient ethnicity. 41 Physician well-being was explored by Mosquera et al, 68 who found that EHR use logs correlate with validated measures of burnout among psychiatry residents.…”