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Could Implicit Bias Affect Imaging Screens in the Pediatric ED? – PatientEngagementHIT.com

Posted: February 5, 2021 at 11:55 pm

February 04, 2021 -Black children are 18 percent and Hispanic children are 13 percent less likely to receive diagnostic imaging tests in the emergency department than White children, a trend researchers from the University of Pittsburgh Medical Center (UPMC) and UPMC Childrens Hospital of Pittsburgh said could be a sign of implicit bias.

The analysis, published in JAMA Network Open, looked at more than 13 million pediatric ED visits in 44 childrens hospitals across the country. After looking at how many of those visits resulted in a type of diagnostic imaging plain radiography, computed tomography, ultrasonography, and magnetic resonance imagingthe researchers could determine that White children receive these services more often than Black or Hispanic children.

Imaging was performed in about a third of ED visits for non-Hispanic White children. This is compared to 24 percent of visits for non-Hispanic Black children and 26 percent of visits for Hispanic children.

This trend remained salient even when controlling for health insurance status, diagnosis, and household income, and it was even stronger for ED visits that did not turn into a hospital admission.

Although the data cannot account for needed and unneeded tests, there is a chance these findings signal some overtesting in White children. In other words, White children visiting the ED are getting diagnostic imaging tests done even when a test is not necessary. There is also a chance some undertesting is occurring in children of color, according to the researchers.

READ MORE: What Is Implicit Bias, How Does It Affect Healthcare?

That over- and undertesting could be the result of both patient preference and implicit bias on the part of clinicians, Jennifer Marin, MD, MSc, the studys lead author.

Something else is going on here thats beyond the clinical, thats beyond the diagnoses, Marin, who is also an associate professor of pediatrics, emergency medicine, and radiology at Pitt, and medical director of point-of-care ultrasound at UPMC Childrens Hospital, said in a statement.

For example, parents or guardians of White children visiting the ED may feel more empowered in the childs care management and push harder for diagnostic imaging, even if that imaging is not necessary.

Higher imaging rates observed in non-Hispanic White patients may, in part, be attributed to greater levels of parental anxiety with an associated increase in requests for imaging, the researchers added.

Additionally, implicit bias may lead some clinicians to forego imaging in a child of color. Implicit biases are not intentional slights against patients, but rather are the unconscious preconceived notions clinicians bring with them to patient-provider encounters. In this case, a clinician may not think a patient or her family would prefer diagnostic imaging or be able to afford it.

READ MORE: How Healthcare Is Starting to Heal Damaged Black Patient Trust

Physicians implicit racial biases are an important consideration and have been associated with patient-clinician interactions, treatment decisions, treatment adherence, and patient health outcomes, the researchers said.

Health disparities in access to and quality of health coverage could also be at play. White children may have more diagnostic imaging referrals from primary care providers, while Black or Hispanic children may lack a patient-centered medical home that could provide holistic care.

These findings suggest a need for better implicit bias and cultural competence training in the medical setting. Because the strongest factor at play here is likely implicit bias, which is an unconscious bias, cultural competence and responsiveness would be helpful for clinicians to overcome these unconscious biases.

Cultural factors that come with peoples race, gender, religion, etc., should not be associated with testing when getting that test is clearly not beneficial to the patient and potentially harmful, Marin stated.

None of this is to mention the effect too much or not enough diagnostic imaging could have on actual health outcomes, too. There are significant health risks to both, the researchers said.

READ MORE: Few People See Racial Bias As Driving Racial Health Disparities

Overuse may expose these children to unnecessary risks associated with imaging, they explained in the study.Conversely, underuse may result in misdiagnoses, need for further care, and potentially worse clinical outcomes.

According to Marin, overexposure to diagnostic imaging is especially perilous to children.

An unnecessary CT at five years old is not the same as an unnecessary CT at 70 years old, Marin said. If you think of it in terms of lifetime risk, a five-year-old has 80-ish years to go on and develop malignancy, versus a 70-year-old who only has 15 years.

There is also the issue of medical waste, something that goes against key pillars of value-based and patient-centered care, Marin added.

We may get an image and the radiologist may see somethingand that something may not be of clinical significancethen the child has to be subjected to downstream testing and monitoring, she concluded. Thats an added burden and stress on the family and added cost on the health care system.

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Could Implicit Bias Affect Imaging Screens in the Pediatric ED? - PatientEngagementHIT.com

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