Resident racial and ethnic composition, neighborhood-level socioeconomic status, and COVID-19 infections in California SNFs.

BACKGROUND: In California, >29,000 residents in skilled nursing facility (SNFs) were diagnosed with novel coronavirus disease 2019 (COVID-19) between March 2020 and November 2020. Prior research suggests that SNFs serving racially and ethnically minoritized residents often have fewer resources and lower quality of care. We performed a cross-sectional analysis of COVID-19 incidence among residents in California SNFs, assessing the association of SNF-level racial and ethnic compositions and facility- and neighborhood-level (census tract- and county-level) indicators of socioeconomic status (SES). METHODS: SNFs were grouped based on racial and ethnic composition using data from the Centers for Medicare and Medicaid Services; categories included SNFs with ≥88% White residents, SNFs with ≥32% Black or Latinx residents, SNFs with ≥32% Asian residents, or SNFs not serving a high proportion of any racial and ethnic composition (mixed). SNF resident-level COVID-19 infection data were obtained from the National Healthcare Safety Network from May 25, 2020 to August 16, 2020. Multilevel mixed-effects negative binomial regressions were used to estimate incidence rate ratios (IRR) for confirmed COVID-19 infections among residents. RESULTS: Among 971 SNFs included in our sample, 119 (12.3%) had ≥88% White residents; 215 (22.1%) had ≥32% Black or Latinx residents; 78 (8.0%) had ≥32% Asian residents; and 559 (57.6%) were racially and ethnically mixed. After adjusting for confounders, SNFs with ≥32% Black or Latinx residents (IRR = 2.40 [95% CI = 1.56, 3.68]) and SNFs with mixed racial and ethnic composition (IRR = 2.12 [95% CI = 1.49, 3.03]) both had higher COVID-19 incidence rates than SNFs with ≥88% White residents. COVID-19 incidence rates were also found to be higher in SNFs with low SES neighborhoods compared to those in high SES neighborhoods. CONCLUSION: Public health personnel should consider SNF- and neighborhood-level factors when identifying facilities to prioritize for COVID-19 outbreak prevention and control.

Perceptions of race/ethnicity-based discrimination: a review of measures and evaluation of their usefulness for the health care setting.

BACKGROUND: To assess discrimination in health care, reliable, valid, and comprehensive measures of racism/discrimination are needed. OBJECTIVE: To review literature on measures of perceived race/ethnicity-based discrimination and evaluate their characteristics and usefulness in assessing discrimination from health care providers. METHODS: Literature review of measures of perceived race/ethnicity-based discrimination (1966-2007), using MEDLINE, PsycINFO, and Social Science Citation Index. RESULTS: We identified 34 measures of racism/discrimination; 16 specifically assessed dynamics in the health care setting. Few measures were theoretically based; most assessed only general dimensions of racism and focused specifically on the experiences of African American patients. Acceptable psychometric properties were documented for about half of the instruments. CONCLUSIONS: Additional measures are needed for detailed assessments of perceived discrimination in the health care setting; they should be relevant for a wide variety of racial/ethnic groups, and they must assess how racism/discrimination affects health care decision making and treatments offered.

Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients.

CONTEXT: Studies documenting racial/ethnic disparities in health care frequently implicate physicians' unconscious biases. No study to date has measured physicians' unconscious racial bias to test whether this predicts physicians' clinical decisions. OBJECTIVE: To test whether physicians show implicit race bias and whether the magnitude of such bias predicts thrombolysis recommendations for black and white patients with acute coronary syndromes. DESIGN, SETTING, AND PARTICIPANTS: An internet-based tool comprising a clinical vignette of a patient presenting to the emergency department with an acute coronary syndrome, followed by a questionnaire and three Implicit Association Tests (IATs). Study invitations were e-mailed to all internal medicine and emergency medicine residents at four academic medical centers in Atlanta and Boston; 287 completed the study, met inclusion criteria, and were randomized to either a black or white vignette patient. MAIN OUTCOME MEASURES: IAT scores (normal continuous variable) measuring physicians' implicit race preference and perceptions of cooperativeness. Physicians' attribution of symptoms to coronary artery disease for vignette patients with randomly assigned race, and their decisions about thrombolysis. Assessment of physicians' explicit racial biases by questionnaire. RESULTS: Physicians reported no explicit preference for white versus black patients or differences in perceived cooperativeness. In contrast, IATs revealed implicit preference favoring white Americans (mean IAT score = 0.36, P < .001, one-sample t test) and implicit stereotypes of black Americans as less cooperative with medical procedures (mean IAT score 0.22, P < .001), and less cooperative generally (mean IAT score 0.30, P < .001). As physicians' prowhite implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis (P = .009). CONCLUSIONS: This study represents the first evidence of unconscious (implicit) race bias among physicians, its dissociation from conscious (explicit) bias, and its predictive validity. Results suggest that physicians' unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction.