The Impact of Health Care Algorithms on Racial and Ethnic Disparities : A Systematic Review.

BACKGROUND: There is increasing concern for the potential impact of health care algorithms on racial and ethnic disparities. PURPOSE: To examine the evidence on how health care algorithms and associated mitigation strategies affect racial and ethnic disparities. DATA SOURCES: Several databases were searched for relevant studies published from 1 January 2011 to 30 September 2023. STUDY SELECTION: Using predefined criteria and dual review, studies were screened and selected to determine: 1) the effect of algorithms on racial and ethnic disparities in health and health care outcomes and 2) the effect of strategies or approaches to mitigate racial and ethnic bias in the development, validation, dissemination, and implementation of algorithms. DATA EXTRACTION: Outcomes of interest (that is, access to health care, quality of care, and health outcomes) were extracted with risk-of-bias assessment using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool and adapted CARE-CPM (Critical Appraisal for Racial and Ethnic Equity in Clinical Prediction Models) equity extension. DATA SYNTHESIS: Sixty-three studies (51 modeling, 4 retrospective, 2 prospective, 5 prepost studies, and 1 randomized controlled trial) were included. Heterogenous evidence on algorithms was found to: a) reduce disparities (for example, the revised kidney allocation system), b) perpetuate or exacerbate disparities (for example, severity-of-illness scores applied to critical care resource allocation), and/or c) have no statistically significant effect on select outcomes (for example, the HEART Pathway [history, electrocardiogram, age, risk factors, and troponin]). To mitigate disparities, 7 strategies were identified: removing an input variable, replacing a variable, adding race, adding a non-race-based variable, changing the racial and ethnic composition of the population used in model development, creating separate thresholds for subpopulations, and modifying algorithmic analytic techniques. LIMITATION: Results are mostly based on modeling studies and may be highly context-specific. CONCLUSION: Algorithms can mitigate, perpetuate, and exacerbate racial and ethnic disparities, regardless of the explicit use of race and ethnicity, but evidence is heterogeneous. Intentionality and implementation of the algorithm can impact the effect on disparities, and there may be tradeoffs in outcomes. PRIMARY FUNDING SOURCE: Agency for Healthcare Quality and Research.

Critical Appraisal for Racial and Ethnic Equity in Clinical Prediction Models Extension: Development of a Critical Appraisal Tool Extension to Assess Racial and Ethnic Equity-Related Risk of Bias for Clinical Prediction Models.

Introduction: Despite mounting evidence that the inclusion of race and ethnicity in clinical prediction models may contribute to health disparities, existing critical appraisal tools do not directly address such equity considerations. Objective: This study developed a critical appraisal tool extension to assess algorithmic bias in clinical prediction models. Methods: A modified e-Delphi approach was utilized to develop and obtain expert consensus on a set of racial and ethnic equity-based signaling questions for appraisal of risk of bias in clinical prediction models. Through a series of virtual meetings, initial pilot application, and an online survey, individuals with expertise in clinical prediction model development, systematic review methodology, and health equity developed and refined this tool. Results: Consensus was reached for ten equity-based signaling questions, which led to the development of the Critical Appraisal for Racial and Ethnic Equity in Clinical Prediction Models (CARE-CPM) extension. This extension is intended for use along with existing critical appraisal tools for clinical prediction models. Conclusion: CARE-CPM provides a valuable risk-of-bias assessment tool extension for clinical prediction models to identify potential algorithmic bias and health equity concerns. Further research is needed to test usability, interrater reliability, and application to decision-makers.

Interventions to Reduce Hospital Length of Stay in High-risk Populations: A Systematic Review.

Importance: Many strategies to reduce hospital length of stay (LOS) have been implemented, but few studies have evaluated hospital-led interventions focused on high-risk populations. The Agency for Healthcare Research and Quality (AHRQ) Learning Health System panel commissioned this study to further evaluate system-level interventions for LOS reduction. Objective: To identify and synthesize evidence regarding potential systems-level strategies to reduce LOS for patients at high risk for prolonged LOS. Evidence Review: Multiple databases, including MEDLINE and Embase, were searched for English-language systematic reviews from January 1, 2010, through September 30, 2020, with updated searches through January 19, 2021. The scope of the protocol was determined with input from AHRQ Key Informants. Systematic reviews were included if they reported on hospital-led interventions intended to decrease LOS for high-risk populations, defined as those with high-risk medical conditions or socioeconomically vulnerable populations (eg, patients with high levels of socioeconomic risk, who are medically uninsured or underinsured, with limited English proficiency, or who are hospitalized at a safety-net, tertiary, or quaternary care institution). Exclusion criteria included interventions that were conducted outside of the hospital setting, including community health programs. Data extraction was conducted independently, with extraction of strength of evidence (SOE) ratings provided by systematic reviews; if unavailable, SOE was assessed using the AHRQ Evidence-Based Practice Center methods guide. Findings: Our searches yielded 4432 potential studies. We included 19 systematic reviews reported in 20 articles. The reviews described 8 strategies for reducing LOS in high-risk populations: discharge planning, geriatric assessment, medication management, clinical pathways, interdisciplinary or multidisciplinary care, case management, hospitalist services, and telehealth. Interventions were most frequently designed for older patients, often those who were frail (9 studies), or patients with heart failure. There were notable evidence gaps, as there were no systematic reviews studying interventions for patients with socioeconomic risk. For patients with medically complex conditions, discharge planning, medication management, and interdisciplinary care teams were associated with inconsistent outcomes (LOS, readmissions, mortality) across populations. For patients with heart failure, clinical pathways and case management were associated with reduced length of stay (clinical pathways: mean difference reduction, 1.89 [95% CI, 1.33 to 2.44] days; case management: mean difference reduction, 1.28 [95% CI, 0.52 to 2.04] days). Conclusions and Relevance: This systematic review found inconsistent results across all high-risk populations on the effectiveness associated with interventions, such as discharge planning, that are often widely used by health systems. This systematic review highlights important evidence gaps, such as the lack of existing systematic reviews focused on patients with socioeconomic risk factors, and the need for further research.

Impact of a Hospital Evidence-Based Practice Center (EPC) on Nursing Policy and Practice.

BACKGROUND: In 2006, our healthcare system created a hospital Evidence-based Practice Center (EPC) to support the local delivery of high-quality, safe and high value patient care. Since then, the importance of healthcare staff work life has also been highlighted, and together these four elements form the Quadruple Aim framework. Synergistic to this Aim, the Magnet® program promotes and recognizes organizational nursing excellence. OBJECTIVE: To examine the EPC's work to inform nursing policy and practice in support of the goals of the Quadruple Aim framework and Magnet® designation. METHODS: Methods used included the following: (1) descriptive analysis of the hospital EPC's database of rapid reviews; and (2) administration of a 40-item electronic questionnaire to nurses who requested an EPC review during fiscal years (FY) 2015 and 2016. RESULTS: Of 308 rapid reviews completed in the EPC's first 10 years, 59 (19%) addressed nursing topics. The proportion of reviews relevant to nursing increased from 5% (2/39) in the center's first 2 years to 44% (25/60) in FY 2015-2016. The majority of nursing reviews (39/59) examined processes of care. Of 23 nurses eligible to participate in the survey, 21 responded (91%). Nurses with administrative or managerial responsibilities requested 70% of reviews; clinical nurse specialists and bedside nurses requested 17% and 9%, respectively. Reviews were used to support clinical program development (48%), provide clinical guidance (33%), update nursing policies or procedures (24%) and develop training and curricula (24%). Nurses were satisfied with the hospital EPC reviews (mean; 4.7/5), and 95% indicated they were likely to request a future review. LINKING EVIDENCE TO ACTION: A dedicated hospital EPC in partnership with nursing offers a unique mechanism for promoting a culture of evidence-based practice. Nurses at all organizational levels use the services of a hospital EPC to inform nursing policy and practice and are highly satisfied with the process, supporting the Quadruple Aim and Magnet® designation.