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Racial/Ethnic Disparities and Patient Safety Thursday, November 15, 2007 12:00 – 1:00 p.m. ET. Moderator: Erin R. Stucky, MD, FAAP Pediatric Hospitalist Children’s Specialists of San Diego Rady Children’s Hospital San Diego, California.

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Racial/Ethnic Disparities and Patient Safety Thursday, November 15, 2007 12:00 – 1:00 p.m. ET


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    1. Racial/Ethnic Disparitiesand Patient SafetyThursday, November 15, 200712:00 – 1:00 p.m. ET

    2. Moderator: Erin R. Stucky, MD, FAAP Pediatric Hospitalist Children’s Specialists of San Diego Rady Children’s Hospital San Diego, California

    3. This activity was funded through an educational grant from the Physicians’ Foundation for Health Systems Excellence.

    4. Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities Grid The AAP CME program aims to develop, maintain, and increase the competency, skills, and professional performance of pediatric healthcare professionals by providing high quality, relevant, accessible and cost-effective educational experiences. The AAP CME program provides activities to meet the participants’ identified education needs and to support their lifelong learning towards a goal of improving care for children and families (AAP CME Program Mission Statement, August 2004). The AAP recognizes that there are a variety of financial relationships between individuals and commercial interests that require review to identify possible conflicts of interest in a CME activity. The “AAP Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities” is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying and resolving all potential conflicts of interest prior to the confirmation of service of those in a position to influence and/or control CME content. The AAP has taken steps to resolve any potential conflicts of interest. All AAP CME activities will strictly adhere to the 2004 Updated Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support: Standards to Ensure the Independence of CME Activities. In accordance with these Standards, the following decisions will be made free of the control of a commercial interest: identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the CME activity. The purpose of this policy is to ensure all potential conflicts of interest are identified and mechanisms to resolve them prior to the CME activity are implemented in ways that are consistent with the public good. The AAP is committed to providing learners with commercially unbiased CME activities.

    5. DISCLOSURES

    6. DISCLOSURES

    7. DISCLOSURES

    8. CME CREDIT The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAP designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. This activity is acceptable for up to 1.0 AAP credit. This credit can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.

    9. OTHER CREDIT This webinar is approved by the National Association of Pediatric Nurse Practitioners (NAPNAP) for 1.2 NAPNAP contact hours of which 0.0 contain pharmacology (Rx) content. The AAP is designated as Agency #17. Upon completion of the program, each participant desiring NAPNAP contact hours should send a completed certificate of attendance, along with the required recording fee ($10 for NAPNAP members, $15 for nonmembers), to the NAPNAP National Office at 20 Brace Road, Suite 200, Cherry Hill, NJ 08034-2633. The American Academy of Physician Assistants accepts AMA PRA Category 1 Credit(s)TM from organizations accredited by the ACCME .

    10. Glenn Flores, MD, FAAP Professor of Pediatrics and Public Health Director, Division of General Pediatrics The Judith and Charles Ginsburg Chair in Pediatrics UT Southwestern Medical Center Dallas, Texas

    11. Learning Objectives Upon completion of this activity, you will be able to: • Discuss racial/ethnic disparities in pediatric patient safety and summarize priorities and unanswered questions in the field. • Describe a new conceptual model for understanding racial/ethnic disparities in pediatric patient safety. • Apply this model to improve patient safety for racial/ethnic minority children.

    12. Glenn Flores, MD, FAAP Professor and Director, Division of General Pediatrics Judith and Charles Ginsburg Chair in Pediatrics University of Texas Southwestern Medical Center Children’s Medical Center Dallas, TX Reference: Pediatric Clinics of North America2006;53:1197-1215 Racial/Ethnic Disparities and Patient Safety

    13. Background • Number of racial/ethnic minority children will exceed number of non-Latino white children in US by 2030 • Indeed, from 2030-2050, non-Latino white population will contribute nothing to nation’s population growth because it will decline in size,in contrast to • African-American population, which will double between 1995 and 2050 • Latino population, which will add more people to US every year after 2020 than all other racial/ethnic groups combined

    14. Background • Rapid growth of minorities in US makes it increasingly likely each year that healthcare providers will care for minority patients • Nevertheless, very little known about racial/ethnic disparities in patient safety, particularly when it comes to children. For example, in landmark Institute of Medicine (IOM) report,“To Err is Human:” • Neither race nor ethnicity mentioned • Linguistic issues mentioned very briefly in 3 sentences, and only in reference to access to care or general recommendations

    15. Webinar Goals • Review what we know about racial/ethnic disparities in pediatric patient safety and summarize priorities and unanswered questions in this field • Describe new conceptual model for racial/ethnic disparities in patient safety • Identify what can be done to improve patient safety for racial/ethnic minority children

    16. Helpful Definitions Because substantial variation exists in patient safety terminology, it’s useful to define certain terms • Medical error • Act of commission or omission that substantively increases risk of a medical adverse event • Can result from failure of planned action to be completed as intended (i.e., mishap or error of execution), or use of wrong plan to achieve aim (i.e., error of planning)

    17. Definitions • Error of commission • Medical error resulting in inappropriate increased risk of iatrogenic adverse event(s) from receiving too much or hazardous treatment (overuse or misuse) • Includes quality problems such as excessive medication doses, contraindicated treatments, giving wrong medication, or iatrogenic risk from unneeded interventions • Error of omission • Medical error resulting in an inappropriate increased risk of disease-related adverse event(s) from receiving too little treatment (underuse) • Includes quality problems such as delayed diagnoses, subtherapeutic medication doses, and failure to provide indicated treatments

    18. Definitions • Medical adverse event • Incident resulting in medical injury, complication, worsening health outcomes, or perceived harm (either physical or emotional distress) • Can occur despite appropriate care (such as recognized complications of an intervention or resulting from the person's underlying disease) or can be caused by errors of omission or commission

    19. Definitions • Racial/ethnic disparity • Any difference in health or healthcare among different racial/ethnic groups (using whites as reference group) • Linguistic disparity • Any difference in health or healthcare between those whose primary language is English (the reference group) and those whose primary language is not English and who are limited in English proficiency (LEP, defined as self-rated English speaking ability of less than“very well”)

    20. Review of Medical Literature • Systematic review performed of representative sample of published literature on racial/ethnic disparities in pediatric patient safety to • Identify what’s known and not known about racial/ethnic disparities in pediatric patient safety • Summarize urgent priorities and unanswered questions • Medline search of > 40 years of research (from 1966 to 2006) published in 14 major journals • Search criteria yielded 323 articles

    21. Review of Medical Literature • Very few pediatric patient safety articles have examined racial/ethnic disparities • Of 323 pediatric patient safety articles in systematic review, only 9 (3%) included race/ethnicity in analyses • Only 1 of 323 studies (0.3%) specifically focused on racial/ethnic disparities in patient safety (although it included both children and adults) • 4 studies examined data for both children and adults, but did not perform separate analyses for children by race/ethnicity

    22. Key Findings from Literature: Disparities in Birth Trauma • Analysis of Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs) revealed significantly higher risk of birth trauma in minority newborns. Compared with white newborns, adjusted odds of birth trauma • 1.5 times greater (95% confidence interval [CI], 1.5-1.6) for African-American newborns • 1.2 times greater (95% CI, 1.1-1.2) for Latino newborns • 1.2 times greater (95% CI, 1.1-1.2) for newborns in other racial/ethnic groups • Of note, birth trauma by far most common adverse medical event, accounting for over 36,000 events and event rate of 154 per 10,000 discharges, exceeding event rate (100 per 10,000 discharges) for all 10 other adverse medical event categories combined • Newborns with birth trauma documented to have almost triple in-hospital mortality rate of newborns without birth trauma

    23. Key Findings: Disparities in Infection Due to Medical Care • Analysis of Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs) revealed • African-Americans, Asians/Pacific Islanders, and Latinos had significantly higher rates than whites of infections due to medical care and of post-operative sepsis • Analysis of Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample documented • African-Americans had higher risk than whites of postoperative infectious complications, including sepsis, and infections following infusion, injection, and transfusion • Latinos had somewhat higher risk than whites of postoperative septicemia and infection due to medical care

    24. Key Findings: Disparities in Postoperative Adverse Medical Events • Analysis of Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs) revealed that, compared with white children, • African-American children had significantly higher rates of postoperative hemorrhage/hematoma, decubitus ulcers, and pulmonary embolus or deep vein thrombosis • Asians/Pacific Islander children had significantly higher rate of postoperative hemorrhage/hematoma • African-Americans, Asians/Pacific Islanders, and Latinos had significantly higher rates of postoperative respiratory failure and physiologic/metabolic derangement

    25. Key Findings: Disparities in Postoperative Adverse Medical Events • Analysis of Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample documented that, compared with white children, • African-American children had higher risk of decubitus ulcers, infection following infusion, injection, transfusion, postoperative physiologic and metabolic derangements, and thromboembolism • Latino children had somewhat higher risk of postoperative septicemia, respiratory failure, and physiologic and metabolic derangements

    26. Racial/Ethnic Differences in Perceived Error Severity & Reporting Survey of 499 parents in an ED revealed racial/ethnic differences in parental perceptions of medical error severity and parental preferences for reporting medical errors to a disciplinary body. Compared with white parents, • African-American parents significantly more likely to rate 4 medical error scenarios as more severe (62% vs. 49%, respectively; P < .01) • African-American parents significantly more likely to want party responsible for medical error to be reported to disciplinary organizations (50% vs. 33%; P < .01) • Difference persisted even after adjustment for relevant covariates (relative risk, 1.29; 95% CI,1.02-1.58).

    27. Language Barriers and Higher Risk of Adverse Events Case-control study of 572 children hospitalized at a children’s hospital documented disparities in risk of adverse medical events for children whose families requested Spanish interpreters • Patients and families requesting Spanish interpreters had more than twice the odds of serious medical events (odds ratio, 2.26; 95% CI, 1.06-4.81) compared with thosenot requesting interpreters

    28. Unanswered Questions: Disparities and Patient Safety • Many unanswered questions remain about racial/ethnic disparities in pediatric patient safety • More research needed on racial/ethnic disparities in birth trauma and reasons for disparities • Greater insight needed about minorities’ greater risk for infections due to medical care and for postoperative bleeding, sepsis, respiratory failure, and physiologic/metabolic derangement • Not enough known about racial/ethnic disparities in pediatric patient safety in outpatient setting

    29. Unanswered Questions: Disparities and Patient Safety • More research needed on association of language barriers with medical errors and adverse medical events • When medical errors and adverse medical events occur, need to know more about minorities’ perceptions and preferences regarding severity, disclosure, reporting, disciplinary response, and legal action

    30. New Conceptual Model: Racial/ Ethnic Disparities in Patient Safety New conceptual model proposed to provide more comprehensive, patient- and family-centered framework for understanding disparities in patient safety. Five components of model include: • Higher prevalence of known risk factors for medical errors in minorities • Medical errors of omission and deviations from optimal practice frequent and particularly important for minorities • Adverse medical event definitions often fail to include important minority patient views on what constitutes harm • Language barriers result in higher risk of medical errors and adverse medical events • Data collection systems for identifying and monitoring disparities in patient safety often insufficient or absent

    31. Higher Prevalence of Risk Factors for Medical Errors in Minorities 1st component of model posits minority children at higher risk for patient safety disparities due to high prevalence of known risk factors for medical errors in minority children • Youngest hospitalized children (0-1 year olds) consistently and significantly more likely to experience patient safety events and youngest children (0-3 years old) at greatest risk for outpatient medication errors • Minorities comprise substantially larger proportion of youngest children (0-5 years old) in US than in general US population: 43% of 20 million 0-5 year olds non-white, compared with 32% of US population of all ages • Thus, youngest US children both more likely to be minorities and to be at greater risk for medical errors and adverse medical events

    32. Higher Prevalence of Risk Factors for Medical Errors in Minorities • Neonates in the Neonatal Intensive Care Unit (NICU) experience highest rates of medication errors and potential adverse drug events of any age group of hospitalized children, and at rates exceeding those of general adult population • African-Americans continue to have substantially higher rates of premature, low birth weight, and very low birth weight infants, accounting for their disproportionate representation among NICU admissions (> ½ of NICU admissions African-American) • Thus, African-American infants at high risk for medication errors and potential adverse drug events because of disproportionately greater risk of NICU admission

    33. Higher Prevalence of Risk Factors for Medical Errors in Minorities • Receiving care in ED has been shown to be associated with higher risk of adverse medical events • Multiple studies document that minority children make significantly more ED visits than white children

    34. Importance of Errors of Omission & Deviation from Optimal Practice • Recent work has called attention to importance of medical errors of omission, in which receiving too little treatment (under-use) results in inappropriate increased risk of disease-related adverse medical events • One study found omission errors accounted for 96% of all medical errors • Most common categories of omission errors include obtaining insufficient information from histories and physicals, inadequacies in diagnostic testing, and patients not receiving needed medications • We propose that medical errors of omission a frequent and important patient safety issue for racial/ethnic minority children, in comparison with white children

    35. Importance of Errors of Omission & Deviation from Optimal Practice • Multiple studies document medical errors of omission among minority children and sometimes serious adverse medical events they cause • Language barriers documented to frequently result in insufficient information from histories and physicals for Latino pediatric patients, including • Omission of important information about drug allergies, past medical history, and chief complaint • Critical distortions in psychiatric symptoms • Misinterpretations resulting in quadriplegia and inappropriate placement of children in social services custody for erroneous diagnosis of child abuse

    36. Importance of Errors of Omission & Deviation from Optimal Practice • Example of inadequacies in diagnostic testing: study of children presenting to children’s hospital ED which found Latino children significantly less likely than white children to undergo two or more diagnostic tests or to have x-rays done • Several studies both in US and UK document substantial racial/ethnic disparities in pediatric asthma treatment, such as significantly lower odds of minorities receiving β2 agonists and anti-inflammatory medications

    37. Importance of Errors of Omission & Deviation from Optimal Practice • Stark example of medical errors of omission: study of white psychotherapists in which 2 case histories presented that were identical except for race of adolescent boy (white vs. African-American) • Compared with white adolescent’s case, psychotherapists gave significantly lower ratings for African-American adolescent for clinical significance of 8 of 21 pathological behaviors • White therapists less distressed about African-American adolescent beating his girlfriend, stealing cars, mistrusting interviewer, and hating his mother • Supports hypothesis that mental disorders in African-American adolescents under-diagnosed because their pathological behaviors rated less severely

    38. Importance of Errors of Omission & Deviation from Optimal Practice • Importance of medical errors of omissions in patient safety raises broader conceptual issue: medical error should be defined as any deviation from optimal practice • This critical adjustment in definition of medical error allows powerful systems approach to error prevention in which an error viewed as a system failure that requires system adjustment • Including deviation from optimal practice as a medical error also underscores crucial interrelationship of patient safety, quality of care, and racial/ethnic disparities

    39. Importance of Errors of Omission & Deviation from Optimal Practice • Deviation from optimal practice associated with higher risk of serious adverse medical events for minorities and may contribute substantially to disparities • Study of over 74,000 very low-birth-weight (VLBW) infants in Vermont Oxford Network revealed minority-serving hospitals (those with >35% African-American infants) had significantly higher adjusted infant mortality rates for both African-American and white infants, vs. hospitals serving <15% of African-American infants • Study of 51 New York hospitals documented hospitals with >80% minority discharges had double adjusted odds of adverse events due to negligence (injuries due to interventions that were inappropriate or did not meet standard of care), compared with hospitals with lower proportions of minority discharges

    40. Patient Safety Definitions Often Fail to Include Minority Views on What Harm Is • Research reveals definitions of medical errors and adverse medical events often fail to capture what constitutes harm and error from perspectives of minority patients and families • Qualitative study of white and African-American patients about preventable incidents resulting in perceived harm in primary care and primary care of their children revealed 70% of harms psychological • For African-Americans, among most important incidents: those in which racism or prejudice occurred • Findings suggest patients and families view breakdowns in patient-physician relationship as more prominent medical errors than technical errors in diagnosis and treatment • Failure to accommodate this patient-oriented definition of medical error and harm, particularly regarding perceived bias/prejudice towards minority patients, could lead to ongoing but undetected disparities in patient safety

    41. Language Barriers & Higher Risk of Errors & Adverse Events • Evidence documents language barriers resultin higher risk of medical errors andadverse medical events • Study of pediatric encounters with LEP Latino children and their families revealed 63% of all errors by medical interpreters had potential or actual clinical consequences, with mean of 19 such errors per encounter • Errors committed by ad hoc interpreters (family members and friends) significantly more likely to be errors of potential clinical consequence than those committed by hospital interpreters(77% vs. 53%; P <.0001)

    42. Language Barriers & Higher Risk of Errors & Adverse Events • Errors of clinical consequence in this study included • Omitting questions about drug allergies • Omitting instructions on dose, frequency, and duration of antibiotics and rehydration fluids • Adding that hydrocortisone cream must be applied to entire body, instead of solely to a facial rash • Instructing a mother not to answer personal questions • Omitting that a child already swabbed for a stool culture • Instructing a mother to put amoxicillin in both ears for treatment of otitis media

    43. Language Barriers & Higher Risk of Errors & Adverse Events Study of over 4,000 children seen in ED showed that, compared with English-proficient patients, LEP patients who had either no interpreter or non-medical, ad hoc interpreters, had: • Significantly higher incidence of having medical tests done (OR, 1.5; 95% CI, 1.04-2.2) • Higher test costs (mean difference = $5.73) • Significantly greater likelihood of hospitalization (OR, 2.6; 95% CI, 1.4-4.5) • Significantly greater likelihood of receiving intravenous hydration (OR, 2.2; 95% CI, 1.2-4.3)

    44. Insufficient Data Collection Systems and Patient Safety Disparities • Disparities in patient safety cannot be identified and monitored if data collection systems fail to or inaccurately record patients’ race/ethnicity, primary language spoken at home, and English proficiency • Recent study revealed only 78% of US hospitals systematically collect data on race/ethnicity of patients and only 39% collect data on patients’ primary language • Just 27% of 1,000 hospitals surveyed, however, responded, so these proportions actually may be substantially lower • 51% of hospitals collecting race/ethnicity data reported that admitting clerks determined patients’ race/ethnicity based on observation, a method which • Can result in high rates of inaccuracies, missing data, and classifications in “unknown” and “other” categories • Contradicts expert recommendations that such data be collected by patient self-report

    45. Insufficient Data Collection Systems and Patient Safety Disparities • Another recent survey of 500 US hospitals found that 78% collect patient race information, 50% collect patient ethnicity information, and 50% collect primary language information • Although recording language information highly variable across hospitals and rarely a required field • Survey non-response rate was 55%, so, as with aforementioned survey, these proportions actually may be substantially lower

    46. Insufficient Data Collection Systems and Patient Safety Disparities • These findings indicate that at least 22-50% of US hospitals collect no patient race/ethnicity data and 50-61% collect no primary language data • Unclear whether any hospitals routinely collect data on patients’ English proficiency, a measure that has been shown to be more useful for examining health outcomes • Such insufficiencies and absences in collection of data on race/ethnicity and language can result in failure to identify important patient safety disparities

    47. Two Illustrative Examples: Asthma and Language Barriers • Pediatric asthma and language barrierstwo of clearest and most well researched examples of disparities inpediatric patient safety • Next few slides examine patient safety issues associated with asthma andlanguage barriers, using prior patient safety work and definitions as well ascomponents of proposed conceptual model

    48. Pediatric Asthma and Patient Safety • Disparities in pediatric asthma underscore important patient safety issues and conceptual model components that may perpetuate patient safety disparities • Studies document high prevalence of certain risk factors for medical errors among minority children with asthma • Puerto Rican and African-American children experience greater asthma severity and complexity • Asthmatic children from both groups have significantly higher adjusted odds than white asthmatic children of suffering asthma attack in past year and experiencing more severe wheezing • African-American children substantially more likely than white children to be hospitalized for and die from asthma

    49. Pediatric Asthma and Patient Safety • Greater ED use another risk factor for medical errors • Several studies document African-American and Latino children significantly more likely to make asthma ED visits than white children • Substantial literature documents frequent errors of omission and deviation from optimal care for minority children with asthma. Studies demonstrate minority children with asthma significantly less likely than white children with asthma to receive prescriptions for • 2 agonists • Anti-inflammatory medications • Medications and nebulizers for home use after hospital discharge

    50. Pediatric Asthma and Patient Safety • Studies also document minority children with asthma subject to medical errors of commission, exposing them to inappropriate increased risk of iatrogenic adverse events from receiving too much or hazardous treatment (i.e., overuse or misuse errors) • Among asthmatic children in UK, Afro-Caribbean asthmatic children had 8 times the odds and Indian subcontinent children 4 times the odds of asthmatic white children of receiving contraindicated antitussive prescriptions • African-American children with asthma in Washington state Medicaid system found to have significantly higher adjusted odds than white asthmatic children of receiving theophylline prescriptions, which likely is misuse error representing deviation from optimal therapy