Efforts in Organized Medicine to Eliminate Harmful Race-Based Clinical Algorithms.

This survey study describes efforts to eliminate harmful race-based clinical algorithms among state or territorial medical associations and specialty societies in the US.

Training to Build Antiracist, Equitable Health Care Systems.

All clinicians should provide high-quality, safe, and equitable care to every patient and community. Yet, in practice, health care delivery systems are designed and organized to exacerbate inequity in access and outcomes, and clinicians are incentivized to deliver unequal and inequitable care in deeply segregated academic health centers that are structured to reify white supremacy. This article investigates the nature and scope of health professions educators' obligations to acknowledge harms of segregation in health care as widespread, unjust, iatrogenic, and preventable.

Race and Ethnicity and the Utilization of Security Responses in a Hospital Setting.

BACKGROUND: Security emergency responses (SERs) are utilized by hospitals to ensure the safety of patients and staff but can cause unintended morbidity. The presence of racial and ethnic inequities in SER utilization has not been clearly elucidated. OBJECTIVE: To determine whether Black and Hispanic patients experience higher rates of SER and physical restraints in a non-psychiatric inpatient setting. DESIGN: Retrospective cohort study. PARTICIPANTS: All patients discharged from September 2018 through December 2019. EXPOSURE: Race and ethnicity, as reported by patients at time of registration. MAIN OUTCOMES: The primary outcome was whether a SER was called on a patient. The secondary outcome was the incidence of physical restraints among patients who experienced a SER. KEY RESULTS: Among 24,212 patients, 18,755 (77.5%) patients identified as white, 2,346 (9.7%) as Black, and 2,425 (10.0%) identified with another race. Among all patients, 1,827 (7.6%) identified as Hispanic and 21,554 (89.0%) as non-Hispanic. Sixty-six (2.8%) Black patients had a SER activated during their first admission, compared to 295 (1.6%) white patients. In a Firth logit multivariable model, Black patients had higher adjusted odds of a SER than white patients (adjusted odds ratio (aOR) 1.37 [95% confidence interval: 1.02, 1.81], p = 0.037). Hispanic patients did not have higher odds of having a SER called than non-Hispanic patients. In a Poisson multivariable model among patients who had a SER called, race and ethnicity were not found to be significant predictors of restraint. CONCLUSION: Black patients had higher odds of a SER compared to white patients. No significant differences were found between Hispanic and non-Hispanic patients. Future efforts should focus on assessing the generalizability of these findings, the underlying mechanisms driving these inequities, and effective interventions to address them.

Differences in End-of-Life Care between COVID-19 Inpatient Decedents with English Proficiency and Limited English Proficiency.

Background: Patients with limited English proficiency (LEP) experience lower quality end-of-life (EOL) care. This inequity may have been exacerbated during the COVID-19 pandemic. Objective: Compare health care utilization, EOL, and palliative care outcomes between COVID-19 decedents with and without LEP during the pandemic's first wave in Massachusetts. Methods: Retrospective cohort study of adult inpatients who died from COVID-19 between February 18, 2020 and May 18, 2020 at two academic and four community hospitals within a greater Boston health care system. We performed multivariable regression adjusting for patient sociodemographic variables and hospital characteristics. Primary outcome was place of death (intensive care unit [ICU] vs. non-ICU). Secondary outcomes included hospital and ICU length of stay and time to initial palliative care consultation. Results: Among 337 patients, 89 (26.4%) had LEP and 248 (73.6%) were English proficient. Patients with LEP were less often white (24 [27.0%] vs. 193 [77.8%]; p < 0.001); were more often Hispanic or Latinx (40 [45.0%] vs. 13 [5.2%]; p < 0.001); and less often had a medical order for life-sustaining treatment (MOLST) on admission (15 [16.9%] vs. 120 [48.4%]; p < 0.001) versus patients with English proficiency. In the multivariable analyses, LEP was not independently associated with ICU death, ICU length of stay, or time to palliative care consultation, but was independently associated with increased hospital length of stay (mean difference 4.12 days; 95% CI, 1.72-6.53; p < 0.001). Conclusions: Inpatient COVID-19 decedents with LEP were not at increased risk of an ICU death, but were associated with an increased hospital length of stay versus inpatient COVID-19 decedents with English proficiency.

Electronic Health Record Transition and Impact on Screening Test Follow-Up.

INTRODUCTION: Nonurgent clinically significant test results (CSTRs) are a common cause of missed and delayed diagnoses. However, little is known about the impact of electronic health record (EHR) transitions on CSTR follow-up. This study examines follow-up rates for three CSTRs (incidental pulmonary nodules [IPNs]), prostate-specific antigen [PSA], and Pap smears) before and after EHR transition. METHODS: This is a retrospective cohort study at an urban tertiary medical center using an interrupted time series (ITS) design to assess monthly changes in CSTR follow-up-defined as completion of computed tomography chest imaging 5 to 13 months after first mention of an IPN in a radiology report; completion of a follow-up PSA test, urology visit, or prostate biopsy within 6 months of the first reported PSA > 4; or completion of a colposcopy or gynecology visit within 6 months of a first reported abnormal Pap smear. Patients were included with first-onset abnormal CSTRs for IPN, PSAs > 4, or abnormal Pap smears occurring in the 24 months before and after the EHR transition. RESULTS: There were no significant differences in follow-up in the IPN or the Pap smear ITS models. In the PSA ITS model, follow-up was significantly decreasing (p = 0.0133) in the preintervention period, and there was a significant change in trend from intervention to postintervention (p = 0.0279). CONCLUSION: EHR transition reversed a decreasing trend over time for PSA test follow-up, while IPN and Pap smear follow-up trends did not change significantly. Effects of EHR transition may differ by test studied.

RADAR: A Closed-Loop Quality Improvement Initiative Leveraging A Safety Net Model for Incidental Pulmonary Nodule Management.

BACKGROUND: This study was conducted to assess whether patients with incidental pulmonary nodules (IPNs) received timely follow-up care after implementation of a quality improvement (QI) initiative between radiologists and primary care providers (PCPs). METHODS: A QI study was conducted at an academic medical center for IPNs identified on chest imaging ordered by PCPs, performed between February 1, 2017, and March 31, 2019, and with at least one-year follow-up. A QI initiative, RADAR (Radiology Result Alert and Development of Automated Resolution), was implemented on March 1, 2018, consisting of (1) a novel, electronic communication tool enabling radiologist-generated alerts with time frame and modality for IPN follow-up recommendations, and (2) a safety net team for centralized care coordination to ensure that communication loops were closed. A preintervention IPN cohort was generated through a natural language processing (NLP) algorithm for radiology reports paired with manual chart review. A postintervention IPN cohort was identified using alerts captured in RADAR. The primary outcome was percentage of IPN follow-up alerts resolved on time (defined as receiving follow-up care within the recommended time frame), comparing pre- and postintervention IPN cohorts. Secondary outcomes included agreement between PCPs and radiologists on the recommended follow-up care plan. RESULTS: A total of 218 IPN alerts were assessed following exclusions: 110 preintervention and 108 postintervention. IPN timely follow-up improved from 64.5% (71/110) to 84.3% (91/108) (p = 0.001). Postintervention, there was 87.0% (94/108) agreement between PCPs and radiologists on the recommended follow-up plan. CONCLUSION: The RADAR QI initiative was associated with increased timely IPN follow-up. This safety net model may be scaled to other radiology findings and clinical care settings.

Examining the Potential Impact of Race Multiplier Utilization in Estimated Glomerular Filtration Rate Calculation on African-American Care Outcomes.

BACKGROUND: Advancing health equity entails reducing disparities in care. African-American patients with chronic kidney disease (CKD) have poorer outcomes, including dialysis access placement and transplantation. Estimated glomerular filtration rate (eGFR) equations, which assign higher eGFR values to African-American patients, may be a mechanism for inequitable outcomes. Electronic health record-based registries enable population-based examination of care across racial groups. OBJECTIVE: To examine the impact of the race multiplier for African-Americans in the CKD-EPI eGFR equation on CKD classification and care delivery. DESIGN: Cross-sectional study SETTING: Two large academic medical centers and affiliated community primary care and specialty practices. PARTICIPANTS: A total of 56,845 patients in the Partners HealthCare System CKD registry in June 2019, among whom 2225 (3.9%) were African-American. MEASUREMENTS: Exposures included race, age, sex, comorbidities, and eGFR. Outcomes were transplant referral and dialysis access placement. RESULTS: Of 2225 African-American patients, 743 (33.4%) would hypothetically be reclassified to a more severe CKD stage if the race multiplier were removed from the CKD-EPI equation. Similarly, 167 of 687 (24.3%) would be reclassified from stage 3B to stage 4. Finally, 64 of 2069 patients (3.1%) would be reassigned from eGFR > 20 ml/min/1.73 m2 to eGFR ≤ 20 ml/min/1.73 m2, meeting the criterion for accumulating kidney transplant priority. Zero of 64 African-American patients with an eGFR ≤ 20 ml/min/1.73 m2 after the race multiplier was removed were referred, evaluated, or waitlisted for kidney transplant, compared to 19.2% of African-American patients with eGFR ≤ 20 ml/min/1.73 m2 with the default CKD-EPI equation. LIMITATIONS: Single healthcare system in the Northeastern United States and relatively small African-American patient cohort may limit generalizability. CONCLUSIONS: Our study reveals a meaningful impact of race-adjusted eGFR on the care provided to the African-American CKD patient population.

Addressing the caste system in U.S. healthcare in the era of COVID-19.

In healthcare, we find an industry that typifies the unique blend of racism, classism, and other forms of structural discrimination that comprise the U.S. caste system-the artificially-constructed and legally-reinforced social hierarchy for assigning worth and determining opportunity for individuals based on race, class, and other factors. Despite myths of meritocracy, healthcare is actually a casteocracy; and conversations about racism in healthcare largely occupy an echo chamber among the privileged upper caste of hospital professionals. To address racism in healthcare, we must consider the history that brought us here and understand how we effectively perpetuate an employee caste system within our own walls.

Reducing Medication Waste While Improving Access to Sugammadex: A Quality Improvement Project in Medication Stewardship.

The relatively high cost of sugammadex compared to neostigmine limits its widespread use to reverse neuromuscular blockade, despite its faster onset and more complete clinical effect. While ensuring timely access to sugammadex is important in improving perioperative safety, it is also vital to control unnecessary spending. We describe a quality improvement initiative to reduce excess spending on sugammadex while improving access for anesthesia providers. Monthly spending on sugammadex decreased by 52% ($70,777 vs $33,821), while medication access increased via automated medication dispensers in each operating room. Clinical usage decreased by one-third, with presumed increased adherence to dosing guidelines.

Adoption of a Closed-Loop Communication Tool to Establish and Execute a Collaborative Follow-Up Plan for Incidental Pulmonary Nodules.

OBJECTIVE. The purpose of this study is to assess radiologists' adoption of a closed-loop communication and tracking system, Result Alert and Development of Automated Resolution (RADAR), for incidental pulmonary nodules and to measure its effect on the completeness of radiologists' follow-up recommendations. MATERIALS AND METHODS. This retrospective study was performed at a tertiary academic center that performs more than 600,000 radiology examinations annually. Before RADAR, the institution's standard of care was for radiologists to generate alerts for newly discovered incidental pulmonary nodules using a previously described PACS-embedded software tool. RADAR is a new closed-loop communication tool embedded in the PACS and enterprise provider workflow that enables establishing a collaborative follow-up plan between a radiologist and referring provider and helps automate collaborative follow-up plan tracking and execution. We assessed RADAR adoption for incidental pulmonary nodules, the primary outcome, in our thoracic radiology division (study period March 9, 2018, through August 2, 2018). The secondary outcome was the completeness of follow-up recommendation for incidental pulmonary nodules, defined as explicit imaging modality and time frame for follow-up. RESULTS. After implementation, 106 of 183 (58%) incidental pulmonary nodules alerts were generated using RADAR. RADAR adoption increased by 75% during the study period (40% in the first 3 weeks vs 70% in the last 3 weeks; p < 0.001 test for trend). All RADAR alerts had explicit documentation of imaging modality and follow-up time frame, compared with 71% for non-RADAR alerts for incidental pulmonary nodules (p < 0.001). CONCLUSION. A closed-loop communication system that enables establishing and executing a collaborative follow-up plan for incidental pulmonary nodules can be adopted and improves the quality of radiologists' follow-up recommendations.