What is “Heads Up?”

1. What is “Heads Up?” • 2007 AAPA Committee on Diversity Project • 90 days in University of Washington Shuttles • 3 signs, each up on 5 buses for one month

3. What is Heads Up? Initial Project Goals: • Engage Clinicians and Clinicians in Training • Spotlight Racial Health Disparities • Create focus on Implicit Bias/Stereotyping

4. What is Heads Up? • Transitioned now to CME module • Creation of PA School Curriculum Module

5. Define “Racial Health Disparities” Even with the same access to care, racial and ethnic minorities receive poorer care than white patients (IOM’s “Unequal Treatment,” 2003)

6. IOM’s 2003 Unequal Treatment Landmark review of data, indicating consistent disparities in care: “Racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access-related factors, such as patient's insurance status and income, are controlled." Unequal Treatment, page 1

7. Disparities in Cardiovascular Care • African Americans 28% more likely to die than white Americans from cardiovascular disease, yet African Americans referred less frequently for cardiac catheterization • Whites being treated in emergency rooms for chest pain more likely to receive cardiac catheterization than African Americans • Likelihood of having hospital-based cardiac procedures consistently greater for whites than for African Americans http://www.aapa.org/clinissues/disparitiestables.html#table1

8. Disparities in Cardiovascular Care • Likelihood of having cardiac procedure nearly three times greater for whites than for African Americans • African Americans and Hispanics received less-frequent coronary artery bypass grafts than whites with similar diagnoses • Fewer non-whites underwent cardiac catheterization when meeting initiation criteria http://www.aapa.org/clinissues/disparitiestables.html#table1

9. Disparities in Cardiovascular Care • In patients with acute myocardial infarction, African Americans less likely than whites to receive thrombolytic therapy, coronary arteriography and coronary artery bypass surgery • In patients discharged from hospital stays after definite or possible myocardial infarctions, Mexican Americans received significantly fewer medications than whites http://www.aapa.org/clinissues/disparitiestables.html#table1

10. Racial Disparities in Treatment of Pain • racial and ethnic disparities in pain perception, assessment found in all settings • postoperative, emergency room, across all types of pain (acute, cancer, chronic nonmalignant)

11. Racial Disparities in Treatment of Pain • Disparities persist after controlling for comorbidities, insurance status, treatment, patient preferences, and access to care

12. “Implicit Bias” and “Unconscious Stereotyping” Research indicates: • Implicit biases are pervasive. • People are often unaware of their implicit biases • Ordinary people harbor negative associations in relation to various groups

13. “Implicit Bias” and “Unconscious Stereotyping” • Implicit biases predict behavior • People differ in levels of implicit bias

14. Implicit Association Test (IAT) • “Project Implicit”: network of laboratories, technicians, and research scientists at Harvard University, the University of Washington, and the University of Virginia • Initially launched as a demonstration website in 1998 at Yale University, and began to function fully as a research enterprise following a grant from the National Institute of Mental Health in 2003

15. Implicit Association Test (IAT) • Series of online assessments related to multilple groups (sexual orientation, race, gender, religion) • Feedback and assessment results immediate

17. Implicit Bias and Clinical Outcomes • Physicians reported no explicit preference for white versus black patients • Implicit Association Test (IAT) revealed implicit preference favoring white Americans

18. Implicit Bias and Clinical Outcomes • IAT revealed implicit stereotypes of black Americans as less cooperative with medical procedures and less cooperative generally • As physicians’ pro-white implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis

19. Dual Process Stereotyping Two distinct methods of stereotyping: • Automatic stereotyping • Goal modified stereotyping Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006

20. Automatic Stereotyping • occurs when stereotypes are automatically activated and influence judgments/behaviors outside of consciousness • Occur regardless of their relevance to the perceivers’ goals Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006

21. Goal Modified Stereotyping • More conscious process, done when specific needs of clinician arise (time constraints, filling in gaps in information needed to make complex decisions Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006

22. Function of Stereotyping • Providers are likely to apply information contained in racial/ethnic stereotypes to interpret symptoms and make decisions • Stereotypes likely to be used when stereotypic information is perceived as clinically relevant, and the decision is complex Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006

23. Healthy People 2010 Goal II: “… to eliminate health disparities among segments of the population, including differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation.”

24. HP 2010 Review in 2006: • Substantial disparities between population groups • Few changes in disparity since the baseline when measured • Overall, no consistent pattern of change in disparity for any population group (except males) http://www.cdc.gov/nchs/ppt/duc2006/hallquist_52.ppt#769,1,Midcourse Assessment of Healthy People 2010 Goal II

25. Creating Equity Reports • tool that allows a clinic/site of care to examine, measure, and address inequalities in the care provided to patients from different cultural backgrounds. • it can help identify areas where things are going well and those where there are opportunities for improvement

26. Creating Equity Reports • can also help with monitoring progress over time toward eliminating inequalities • Promotes goal of providing the highest quality of care to all patients, regardless of their race, ethnicity, language, or socioeconomic status, or sexual orientation

27. Creating Equity Reports STEPS: • pick a process (examples: mammograms, guideline adherence for asthma or diabetes) • collect data ( who gets them, who doesn’t) • compare racial and other cultural groups • assess disparities, create action plan where disparity noted http://www.massgeneral.org/disparitiessolutions/resources.html

28. Web and Other Resources Implicit Association Test: https://implicit.harvard.edu/implicit/ Project Implicit Information Page: http://projectimplicit.net/(Recommended Tests: Race, Arab-Muslim, Gender, Sexuality) "The Police Officer's Dilemma"http://home.uchicago.edu/~jcorrell/TPOD.html and then click on the very bottom linkhttp://backhand.uchicago.edu/Center/ShooterEffect/

29. http://backhand.uchicago.edu/Center/ShooterEffect/

30. Web and Other Resources “Heads Up!” Website: http://www.stop-disparities.org/RESOURCES.html