Vera Pertsovskaya; Divya Shan; Andrew C. Meltzer, MD
Racial Bias in Healthcare
Restraint use, like other disparities in healthcare, can stem from the impact of racial bias in clinical encounters. A disparity, according to the Institute of Medicine in its Unequal Report, is a difference in the quality of healthcare provided to patients that is not attributable to the patients’ wishes or healthcare needs (Smedley et al., 2002). The majority of clinician bias is associated with implicit attitudes, which are unconscious thoughts and feelings that can influence behavior. Clinician bias is common, with physicians often having positive attitudes toward white patients and negative attitudes toward non-white patients (Hall, 2015). A recent systematic review found that health care professionals tend to associate Black patients with being less cooperative, compliant, and responsible in comparison to white patients (Hall, 2015), while another study found that clinicians tend to associate Hispanic patients with medical non-compliance and partaking in risky behaviors (Bean et al., 2013). This bias can manifest in terms of talking to patients with a condescending tone, not providing interpreters when necessary, and not recommending treatment plans due to assumptions about the patient’s likelihood to adhere (Dehon et al., 2017).
Although there is no conclusive evidence to establish a direct relationship between implicit physician bias and clinical decision making (Dehon et al., 2017), implicit bias among healthcare professionals indirectly emerges in terms of access to care, the quality of healthcare received, and health outcomes. For example, a National Healthcare Disparities report found that non-white patients received less patient-centered care and worse overall quality of treatment (U.S. Department of Health and Human Services, 2018). Indeed, analysis of data from 350 EDs across the U.S. found that white patients who present with abdominal pain are nearly three times as likely to be treated with analgesics in comparison to minority patients (Shah, 2015). Additionally, Black patients were both less likely to receive percutaneous coronary intervention after being diagnosed with acute coronary syndrome (Musey, 2016) and thrombolytic therapy for acute ischemic stroke (Aparicio et al., 2015). It also should be noted that even after adjusting for medical comorbidities, Black patients being treated in the ED in comparison to white patients experienced longer wait times and were twice as likely to be triaged to a lower level of acuity (Schrader et al., 2013). These systemic inequities contribute to the higher rates of asthma, diabetes, HIV/AIDS, hypertension, obesity, preterm births, and tuberculosis present among minorities (U.S. Department of Health and Human Services, 2018).
Racial Disparities in Psychiatric Diseases
Disparities are also present between racial groups not only in the access to and utilization of mental health services, but also in receiving appropriate treatment for psychiatric disorders (U.S. Department of Health and Human Services, 1999). While Black patients are 50% less likely to be treated for similar psychiatric disorders as white patients, they are more likely to have chronic conditions, such as major depression (Kessler et al., 2005; Williams et al., 2007). Although it should be noted that research has indicated that clinicians tend to overdiagnose Black patients with schizophrenia (Strakowski et al., 1996). Moreover, when controlling for behavior, traumatic experiences, and other confounding variables, Black adolescents were found to have a higher likelihood of being diagnosed with conduct disorder, whereas white adolescents were more likely to be diagnosed with ADHD (Baglivio et al., 2016). This is significant as these disparities in psychiatric diagnoses and treatments predispose Black patients to poorer health outcomes. These disparities quite possibly arise from the physicians’ implicit biases — physicians who tend to see Black patients as being more aggressive and hostile may diagnose these patients with more severe and chronic disorders. A substantial amount of research, in both the outpatient and inpatient settings, indicates that Black patients are more likely to be seen by healthcare providers as being aggressive which can cause a greater chance of security being called, the patient being involuntarily hospitalized, and placed in both seclusion and in restraints (Rosenfield, 1984; Sleath et al., 1998; Whaley, 1998). For patients who do not have equal access to mental health or drug treatment services, a deteriorating clinical condition may culminate with being restrained in the ED.
Racial Bias in Utilization of Restraints
The lack of standardized thresholds to initiate use of restraints causes the utilization of physical and chemical restraints to be partially determined by the clinician’s implicit bias. Indeed, several studies have indicated that racial disparities are present in the decision to restrain a patient. For example, one study found that 73% of patients who were physically restrained in the ED were Black (Zun, 2003), and another study determined that even when controlling for confounding variables, such as sex, diagnosis, homelessness, age, and violence, Black patients were more likely to be restrained while in the ED (Schnitzer et al., 2020). These racial disparities are consistent even beyond the ED, as a study that used a nationally representative sample of nursing homes in the U.S. found that even when controlling for dementia, fall rate, and ADLs impairments, there is a statistically significant correlation between race and the use of physical restraints (Cassie, 2013). Although states have passed legislation to limit the utilization of restraints in medical facilities, it is clear that a significant racial disparity yet remains.
Smedley, B., Stith, A., & Nelson, A. (2003). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academy Press.
Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., Eng, E., Day, S. H., & Coyne-Beasley, T. (2015). Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. American Journal of Public Health, 105(12), e60–e76. https://doi.org/10.2105/AJPH.2015.302903
Bean, M. G., Stone, J., Moskowitz, G. B., Badger, T. A., & Focella, E. S. (2013). Evidence of nonconscious stereotyping of Hispanic patients by nursing and medical students. Nursing Research, 62(5), 362–367. https://doi.org/10.1097/NNR.0b013e31829e02ec
Dehon, E., Weiss, N., Jones, J., Faulconer, W., Hinton, E., & Sterling, S. (2017). A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine, 24(8), 895–904. https://doi.org/10.1111/acem.13214
Shah, A. A., Zogg, C. K., Zafar, S. N., Schneider, E. B., Cooper, L. A., Chapital, A. B., Peterson, S. M., Havens, J. M., Thorpe, R. J., Jr, Roter, D. L., Castillo, R. C., Salim, A., & Haider, A. H. (2015). Analgesic Access for Acute Abdominal Pain in the Emergency Department Among Racial/Ethnic Minority Patients: A Nationwide Examination. Medical Care, 53(12), 1000–1009. https://doi.org/10.1097/MLR.0000000000000444
Musey, P. I., Jr, Studnek, J. R., & Garvey, L. (2016). Characteristics of ST Elevation Myocardial Infarction Patients Who Do Not Undergo Percutaneous Coronary Intervention After Prehospital Cardiac Catheterization Laboratory Activation. Criticalathways in Cardiology, 15(1), 16–21. https://doi.org/10.1097/HPC.0000000000000069
Schrader, C. D., & Lewis, L. M. (2013). Racial disparity in emergency department triage. The Journal of Emergency Medicine, 44(2), 511–518. https://doi.org/10.1016/j.jemermed.2012.05.010
Aparicio, H. J., Carr, B. G., Kasner, S. E., Kallan, M. J., Albright, K. C., Kleindorfer, D. O., & Mullen, M. T. (2015). Racial Disparities in Intravenous Recombinant Tissue Plasminogen Activator Use Persist at Primary Stroke Centers. Journal of the American Heart Association, 4(10), e001877. https://doi.org/10.1161/JAHA.115.001877
(1999) Mental health: a report of the Surgeon General. [Rockville, MD.: Dept. of Health and Human Services, U.S. Public Health Service ; Pittsburgh, PA: For sale by the Supt. of Docs] [Web.] Retrieved from the Library of Congress, https://lccn.loc.gov/2002495357
Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A., Walters, E. E., Wang, P., Wells, K. B., & Zaslavsky, A. M. (2005). Prevalence and treatment of mental disorders, 1990 to 2003. The New England Journal of Medicine, 352(24), 2515–2523. https://doi.org/10.1056/NEJMsa043266
Williams D. R. (2005). The health of U.S. racial and ethnic populations. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 60 Spec No 2, 53–62. https://doi.org/10.1093/geronb/60.special_issue_2.s53
Baglivio, M. T., Wolff, K. T., Piquero, A. R., Greenwald, M. A., & Epps, N. (2017). Racial/Ethnic Disproportionality in Psychiatric Diagnoses and Treatment in a Sample of Serious Juvenile Offenders. Journal of Youth and Adolescence, 46(7), 1424–1451. https://doi.org/10.1007/s10964-016-0573-4
Rosenfield S. (1984). Race differences in involuntary hospitalization: psychiatric vs. labeling perspectives. Journal of Health and Social Behavior, 25(1), 14–23.
Sleath, S. (1998). Patient race and psychotropic prescribing during medical encounters. Patient Education and Counseling, 34(3), 227–238. https://doi.org/10.1016/S0738-3991(98)00030-5
Whaley, A. (1998). RACISM IN THE PROVISION OF MENTAL HEALTH SERVICES: A Social-Cognitive Analysis. American Journal of Orthopsychiatry, 68(1), 47–57. https://doi.org/10.1037/h0080269.
Zun L. S. (2003). A prospective study of the complication rate of use of patient restraint in the emergency department. The Journal of Emergency Medicine, 24(2), 119–124. https://doi.org/10.1016/s0736-4679(02)00738-2
Schnitzer, K., Merideth, F., Macias‐Konstantopoulos, W., Hayden, D., Shtasel, D., & Bird, S. (2020). Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting. Academic Emergency Medicine, 27(10), 943–950. https://doi.org/10.1111/acem.14092
Cassie, K. M., & Cassie, W. (2013). Racial disparities in the use of physical restraints in U.S. nursing homes. Health & Social Work, 38(4), 207–213. https://doi.org/10.1093/hsw/hlt020