PURPOSEWe investigated whether clinicians' explicit and implicit ethnic/racial bias is related to black and Latino patients' perceptions of their care in established clinical relationships. METHODSWe administered a telephone survey to 2,908 patients, stratifi ed 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 fi rst studies to investigate clinicians' implicit bias and communication processes in ongoing clinical relationships. Our fi ndings 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 fi nding 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. Ann Fam Med 2013;11:43-52. doi:10.1370/afm.1442. INTRODUCTIONP rimary care clinicians serve as the cornerstone of the health care system and are required to possess many skills. Patient-centeredness is 1 of 6 key dimensions of high-quality health care, 1 and if clinicians are to provide such care, they must be able to engage patients in a collaborative partnership.The importance of the clinician-patient relationship is underscored by demonstrated links between the quality of the relationship and a number of processes and outcomes of care, including patients' adherence to medical advice, [2][3][4][5][6] decision to remain with a clinician, 7 satisfaction with care, 3 and clinical outcomes of care. 3,8,9 Ethnic/racial minorities appear to be at a disadvantage in this aspect of health care. [10][11][12][13][14][15][16][17] In addition to cultural and language barriers, there have been long-standing concerns that clinician bias may contribute to lowerquality clinical relationships. 44 CL INICIA NS' BIA S PR EDIC T S C A R E PERCEP T IONSBut also, "[there is] strong but circumstantial evidence for the role of bias, stereotyping, prejudice, and clinical uncertainty" in the genesis of health disparities. The observation that clinicians are unlikely to directly express ethnic/racial bias yet may still deliver care that is infl uenced by...
APACHE III accurately predicted aggregate hospital mortality in an independent sample of U.S. ICU admissions. Further improvements in calibration can be achieved by more precise disease labeling, improved acquisition and weighting of neurologic abnormalities, adjustments that reflect changes in treatment outcomes over time, and a larger national database.
Background Although readmission following hospitalization for heart failure (HF) 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 semi-structured 30-60 minute interviews of patients (n=28) readmitted within 6 months of index HF admission. Established qualitative approaches were used to analyze and 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 non-white, 50% were married, 32% had preserved ejection fraction, and median time from discharge to readmission was 31 days. Reasons for readmission were multi-factorial 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 regarding HF 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 versus not preventable, and not easily attributed to a single cause. These findings suggest that future interventions designed to reduce HF readmissions should be multi-faceted, systemic in nature, and integrate patient input.
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