Background: Disparities exist in the care and outcomes of racial/ethnic minorities in the US, including children in the pediatric emergency department (ED). Research suggests that provider implicit bias plays a role in healthcare disparities. The implicit association test (IAT) enables measurement of implicit attitudes via tests of automatic associations between concepts. Hundreds of studies have examined implicit attitudes in various settings, but relatively few have been conducted in healthcare. Objectives: To synthesize the current knowledge on the role of implicit bias in healthcare disparities. Methods: We searched 4 databases for key words related to healthcare providers, implicit bias, and race/ethnicity. After screening to exclude ineligible articles, two independent reviewers performed data abstraction of full texts for relevant articles. Results: Our search yielded 6249 articles and we identified 33 qualifying studies. Thirty studies found evidence of pro-White/anti-Black or Latino bias among a variety of healthcare providers. Types of providers included physicians (e.g., pediatric, surgery, emergency medicine, internal medicine), physician assistants, counselors, nurses, psychologists, occupational therapists, and healthcare students. Three studies focused on implicit bias in the pediatric setting. Two found that implicit racial bias was associated with racial disparities in pain management. One found that cognitive stressors in the pediatric ED were associated with higher levels of bias among residents post-ED shift compared to pre-shift. One additional study in the general ED setting found that increased bias was associated with disparities in chest pain management. Thirteen studies examined the association between implicit bias and healthcare outcomes using clinical vignettes or simulated patients, yielding mixed results. Seven found no association between implicit bias and patient care. However, six studies found that higher implicit bias was associated with disparities in treatment recommendations, expectations of therapeutic bonds, pain management, and empathy. Six studies examined the impact of implicit provider bias on real-world patient care. Only 1 found no association between IAT scores and healthcare disparities. However, 5 found that providers with stronger implicit bias demonstrated poorer patient-provider communication and worse psychosocial outcomes for their patients. Only 4 studies tested interventions aimed at reducing bias. Two examined the effect of multicultural training, but only 1 found a post-intervention reduction in implicit bias. Two studies attempted to reduce implicit bias using team-focused goals or cultural competency virtual training, but found no effect. Conclusion: A growing body of research suggests that most healthcare providers across multiple levels of training and disciplines have implicit racial bias. However, research on the effect of implicit bias on healthcare outcomes using clinical vignettes, simulated patients, and studies of real-world patient encounters has found mixed results. Research indicates that implicit bias predicts poor outcomes in provider communication and interaction with both standardized and actual patients. Few studies have attempted to reduce implicit racial bias in healthcare providers, and only one study was able to show bias reduction. Future studies have the opportunity to build on this current body of research, and in doing so will enable us to achieve equality in healthcare and outcomes for all.
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Section on Emergency Medicine Program| January 01 2018
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Ivy Maina; A Systematic Review of Implicit Racial Bias in Healthcare. Pediatrics January 2018; 141 (1_MeetingAbstract): 337. 10.1542/peds.141.1MA4.337
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