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Intersection of Bias, Structural Racism, and Social Determinants with Health Care Inequities Tiffani J

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Intersection of Bias, Structural Racism, and Social Determinants with Health Care Inequities Tiffani J Intersection of Bias, Structural Racism, and Social Determinants With Health Care Inequities Tiffani J. Johnson, MD, MSc Race, and more specifically, racism, is care disparities.5 Implicit bias is recognized as an important social pervasive in society, and research has determinant of health (SDoH) and a key demonstrated that health care – driver of health inequities.1 3 The study providers have similar levels of implicit “Race, Postoperative Complications, racial bias as the general population.6 and Death in Apparently Healthy Research on the impact of provider bias Children” in this issue of Pediatrics on medical decision-making has been provides new evidence of race as focused largely on adult patient a critical social determinant of populations and has revealed mixed surgical outcomes.4 The investigators results.6 However, one study revealed demonstrate that apparently healthy that pediatric providers with greater Black children had a higher risk of implicit bias were more likely to postoperative mortality, complications, prescribe narcotic medications for Department of Emergency Medicine, University of California, and serious adverse events than their postsurgical pain for white children Davis, Sacramento, California 7 white counterparts. Identifying these than Black children. In adult patient Opinions expressed in these commentaries are disparities using the National Surgical populations, there is robust evidence those of the author and not necessarily those of the Quality Improvement Program that physicians with more implicit bias American Academy of Pediatrics or its Committees. pediatric database highlights the demonstrate higher verbal dominance DOI: https://doi.org/10.1542/peds.2020-003657 importance of health care practices to in their communication styles and are Accepted for publication May 22, 2020 more deliberately consider equity in rated lower in patient-centered care Address correspondence to Tiffani J. Johnson, MD, their quality improvement portfolios. measures, including trust and MSc, Department of Emergency Medicine, University The analyses were done among interpersonal treatment (eg, showing of California, Davis, 4150 V St, Suite 2100, children with American Society of care, concern, and respect).8–14 Patients Sacramento, CA 95817. E-mail: [email protected] Anesthesiologists physical status 1 of providers with more implicit bias PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, (normal healthy patients) or 2 (patients also report less satisfaction with care 1098-4275). with mild systemic disease, such as and less confidence in treatment Copyright © 2020 by the American Academy of mild asthma). By excluding children recommendations.14 Although more Pediatrics with significant comorbidities, this research is needed to understand the FINANCIAL DISCLOSURE: The author has indicated study helps advance knowledge beyond impact of bias on communication and she has no financial relationships relevant to this most previous pediatric disparities medical decision-making in pediatric article to disclose. research focused on identifying patients, there is sufficient evidence to FUNDING: No external funding. disparities by exploring potential root suggest that eliminating health care POTENTIAL CONFLICT OF INTEREST: The author has causes. The findings suggest that, disparities requires providers to indicated she has no potential conflicts of interest to although preoperative comorbidities identify and mitigate the effects of their disclose. have previously been proposed as own implicit bias on patients and COMPANION PAPER: A companion to this article can a factor contributing to postoperative families. be found online at www.pediatrics.org/cgi/doi/10. 1542/peds.2019-4113. disparities, they do not explain the results in the current study. Others have suggested that the association of patient-level To cite: Johnson TJ. Intersection of Bias, Structural Implicit racial bias has been proposed sociodemographics with postoperative Racism, and Social Determinants With Health Care Inequities. Pediatrics. 2020;146(2):e2020003657 as another potential source of health mortality is related to system-level Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 146, number 2, August 2020:e2020003657 COMMENTARY factors, including access to care, markets), learn (eg, equitable ABBREVIATION location of care, and institution education system), and play (eg, safe type.15 This highlights the important playgrounds). SDoH: social determinant of health intersection of structural racism and SDoHs with health care inequities. Eliminating disparities also requires Structural racism refers to policies, addressing systems in place in clinics laws, and regulations that and hospitals that perpetuate systematically result in differential inequities. For example, health care REFERENCES access to services and opportunities systems should consider which health 1. Paradies Y, Ben J, Denson N, et al. 16 in society based on race. One insurance plans they accept and how Racism as a determinant of health: example of structural racism is this may disproportionately deny a systematic review and meta-analysis. redlining, which refers to a practice access to care for children of color.23 PLoS One. 2015;10(9):e0138511 by the federal Home Owners’ Loan Health care leaders should also be 2. Gee GC. Leveraging the social Corporation in which neighborhoods mindful of strategies to improve their determinants to build a culture of were marked as hazardous with red payer mix, which has been described health: racism as a social determinant ink on maps largely on the basis of as coded language for restricting or of health inequities. 2016. Available at: racial demographics.17 This resulted denying care to publicly insured https://healthequity. in not only systematic denial of patients.23 Instead, efforts should be globalpolicysolutions.org/wp-content/ mortgage lending but also denial of made to bring high-quality health uploads/2016/12/RWJF_SDOH_Final_ other capital investments and care to underserved communities as Report-002.pdf. Accessed May 1, 2020 services, such as public a strategy to reduce pediatric 3. Gee GC, Ford CL. Structural racism and transportation, supermarkets, and health care inequities. Providers health inequities: old issues, new health care facilities in communities should also consider the American directions. Du Bois Rev. 2011;8(1): – of color. Historic injustices, such as Academy of Pediatrics’ recently 115 132 redlining, orchestrated the current published policy statement, “The 4. Nafiu OO, Mpody C, Kim SS, Uffman JC, residential segregation that we see in Impact of Racism on Child and Tobias JD. Race, postoperative society, which fuels health care Adolescent Health,”24 which provides complications, and death in apparently disparities by systematically several strategies on how to optimize healthy children. Pediatrics. 2020; 146(2):e20194113 influencing health care access, use, clinical practice to ameliorate the – and quality.18 20 More recently, effects of racism on child health 5. van Ryn M. Research on the provider gentrification in cities across the and health care. Policies and contribution to race/ethnicity country is leading to marginalized programs that support racial diversity disparities in medical care. Med Care. 2002;40(suppl 1):I140–I151 populations being priced out of in the medical workforce are also neighborhoods and displaced into the needed as a strategy to reduce 6. Maina IW, Belton TD, Ginzberg S, Singh peripheries of society with disparities.25 A, Johnson TJ. A decade of studying inadequate transit systems. This implicit racial/ethnic bias in healthcare providers using the implicit association results in decreased access to Although this research sheds light on test. Soc Sci Med. 2018;199:219–229 supermarkets, employment concerning pediatric disparities and fl opportunities, and high-quality health examines potential root causes, there 7. Sabin JA, Greenwald AG. The in uence care.21 Addressing pediatric health remains a critical need to develop and of implicit bias on treatment recommendations for 4 common care disparities, therefore, requires rigorously evaluate effective pediatric conditions: pain, urinary tract interventions to reduce avoidable and dismantling policies that drive SDoHs infection, attention deficit hyperactivity disproportionately experienced by unjust inequities in pediatric health disorder, and asthma. Am J Public communities of color. Health care care. In addition to traditional quality Health. 2012;102(5):988–995 systems can address SDoHs by improvement and research 8. Cooper LA, Roter DL, Carson KA, et al. approaches to address disparities, serving as anchor institutions and The associations of clinicians’ implicit supporting economic growth in achieving child health equity attitudes about race with medical visit communities that have historically necessitates dismantling the policies communication and patient ratings of experienced systematic denial of and structures that perpetuate interpersonal care. Am J Public Health. capital investments from policies like inequities. Pediatric providers and 2012;102(5):979–987 22 redlining. Pediatric medical and organizations can begin by identifying 9. Blair IV, Steiner JF, Fairclough DL, et al. surgical providers can address SDoH and confronting our own biases and Clinicians’ implicit ethnic/racial bias by advocating for policies that have serving as antiracism advocates and perceptions of care among black a positive impact on
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