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Pharmacologic Restraint Use: When Bias Plays a Role

December 19, 2022

Editor’s Note: Eli Cahan is a first-year pediatric resident at University of California, San Francisco and an investigative journalist whose work focuses on the intersection of health equity and social justice.
-Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics

Since May 2020, when George Floyd was killed by a police officer in Minneapolis, Americans have reckoned with the disproportionate effects of police violence on communities of color.

But the ripples of Floyd’s murder, and the protests that followed, reached far beyond policing alone. Institutions of all shapes and sizes were forced to confront the unseemly realities of how they failed to combat—and sometimes even perpetuated—racial injustice.

Healthcare organizations have been no exception.

Hospitals across the country have taken care to enhance their engagement with community advocacy and civic service initiatives to try to better address social determinants of health in the regions they live and serve. Internally, they’ve expanded diversity, equity, and inclusion efforts, attempting to right long-standing inequities in which communities are represented—including in leadership roles.

Nonetheless, studies continue to demonstrate the disparate impacts implicit bias and structural racism in healthcare have on communities of color.

One such study—a multi-institution effort, led by Dr. Ashley Foster from the University of California, San Francisco, and that spanned children’s hospitals coast-to-coast—is being early released this week by Pediatrics titled, “Disparities in Pharmacologic Restraint Use in Pediatric Emergency Departments” (10.1542/peds.2022-056667). The article evaluates the very real ways in which entrenched implicit bias and structural racism continue to lead to differential treatment of children based on race.

The authors, who also hailed from Boston Children’s and Lurie Children’s, reviewed how emergency medicine clinicians responded to youth presenting with agitation. Specifically, they evaluated how, and when, pharmacologic restraints were used across over 500,000 emergency department (ED) visits.

Overall, Foster and colleagues found that pharmacologic restraints were implemented in 1 out of every 25 visits. But restraint use was not exercised equally across patient groups: Black youth were 22% more likely to be the victims of pharmacologic restraint use than whites, and males were 25% more likely to be restrained using medication than were females.

The disparities were particularly stark for those with pre-existing diagnoses of what the authors refer to as “serious mental illness”—including schizophrenia, bipolar, and depressive disorders. In those with pre-existing serious mental illness, Black youth were more than twice as likely to be medically restrained.

The inequities were also amplified in patients who had previously had an emergency visit for mental illness. Pharmacologic restraint use was 31% more likely in individuals with repeat ED visits than newcomers; in Black youth, pharmacologic restraint use was 54% more likely for established patients, outpacing the broader trend.

Foster and colleagues also discovered other factors illuminating the ways in which subjective biases may creep into the care of patients presenting with agitation. For example, pharmacologic restraint use was 68% and 26% more common on nights and weekends, respectively—even after adjusting for other patient-specific characteristics. These trends suggest that factors beyond individual patients alone—such as staffing levels or provider fatigue—may play a role in medical restraint use (as opposed to non-pharmacologic strategies such as verbal de-escalation).

In summary, this study—which is accompanied by a video abstract—represents a critical read for clinicians interested in understanding the concrete ways in which structural bias manifests in health systems today to exacerbate racial (among other) inequities.

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