Implicit Racial Bias and Unintentional Harm in Vascular Care

Published in the JAMA Surgery. Here is a link to the article.

Regenstrief Institute authors: Andrew Gonzalez, M.D., J.D., MPH

Importance

Implicit bias may influence physician treatment decisions and contribute to Black-White health disparities. There are limited data linking implicit bias with actual care delivery and outcomes.

Objective

To determine whether implicit racial bias is associated with potentially harmful surgical treatment selection for a cohort of patients with peripheral artery disease–related claudication.

Design, Setting, and Participants

This survey study, linked with observational registry data, included eligible clinicians who participate in the Vascular Quality Initiative (VQI) among 960 centers. The VQI includes academic medical centers, teaching hospitals, community hospitals, and private practices. Eligible participants included all vascular specialist VQI members (N = 2512), of whom 218 completed the race implicit association test (IAT) and were linkable to procedure-level data. The study was conducted between October 2021 and October 2022.

Exposure

Race IAT.

Main Outcomes and Measures

Clinician-level implicit bias results were linked to patient-level registry data of peripheral revascularization procedures performed for claudication. The adjusted odds of performance of any infrapopliteal procedure by specialist implicit bias and patient race were measured via mixed-effects logistic regression models. Implicit bias as a moderator of the association of infrapopliteal procedures for claudication and patient race with 1-year amputation was assessed as a secondary outcome.

Results 

Among 218 vascular specialists (mean [SD] age, 46 [9] years; 160 [73%] male), 157 (72%) had a pro-White bias. Black patients treated by a physician with pro-White bias had a significant increase in the odds of receiving an infrapopliteal procedure compared with the total sample (adjusted odds ratio [AOR], 1.67; 95% CI, 1.12-2.48). When treated by a specialist with pro-White bias, Black patients had increased odds of 1-year amputation, regardless of anatomic location treated, compared with White patients (AOR, 2.34; 95% CI, 1.20-4.55). Conversely, Black patients treated by a specialist with no bias had similar odds of an infrapopliteal procedure (AOR, 0.93; 95% CI, 0.68-1.26) as the full patient sample and similar odds of 1-year amputation (AOR, 1.29; 95% CI, 0.33-4.99) as White patients.

Conclusions and Relevance 

These findings indicate that implicit bias is associated with potentially harmful infrapopliteal procedures for Black patients and contributes to Black-White outcome disparities in the US. These results suggest the need for system-level interventions that transparently identify and warn of procedures not aligned with best practices to reduce the negative influence of implicit bias.

Authors:

Corey A Kalbaugh ¹, Erika T Beidelman ¹, Kerry A Howard ^{2 3}, Brian Witrick ², Ashley Clark ⁴, Katharine L McGinigle ⁵, Samantha Minc ⁶, Olamide Alabi ⁷, Caitlin W Hicks ⁸, Andrew A Gonzalez ^{9 10}, Crystal W Cené ¹¹, Samuel Cykert ¹²

Affiliations:

¹Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington.

²Department of Public Health Sciences, Clemson University, Clemson, South Carolina.

³Center for Public Health Modeling and Response, Clemson University, Clemson, South Carolina.

⁴Center for Survey Research and O’Neill School of Public and Environmental Affairs, Indiana University-Bloomington, Bloomington.

⁵Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill.

⁶Department of Cardiovascular and Thoracic Surgery, West Virginia School of Medicine, Morgantown.

⁷Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.

⁸Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

⁹Department of Surgery, Indiana University School of Medicine; Indianapolis.

¹⁰Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana.

¹¹Department of Medicine, University of California at San Diego Health, La Jolla.

¹²Division of General Medicine and Clinical Epidemiology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill.