Jeffrey Bendix, Senior Editor

Language used to describe patients in electronic health records may be perpetuating racial bias and other negative stereotypes in health care, a new study suggests.

Using machine learning techniques, researchers analyzed potentially stigmatizing language in more than 40,000 history and physical notes in EHRs from 18,459 adult patients at an academic medical center in Chicago. They found that the odds of Black patients having one or more negative terms, such as “refused,” “(not) compliant” and “agitated” applied to them were more than twice (2.54) those of white patients, even after adjusting for sociodemographic and health characteristics.

The differences were not solely race-based. Medicare and Medicaid beneficiaries, for example, were more likely to have negative descriptors applied to them than were patients with commercial or employer-based insurance, as were unmarried patients compared to patients who were married.

The findings are especially troubling, they say, given that other studies have found that less than 20% of text in inpatient progress notes are original, with most of the rest imported from prior documentation. As a result, “subsequent providers may read, be affected by, and perpetuate the negative descriptors, reinforcing stigma to other health care teams,” they write.

The researchers found that notes written for outpatient visits were less likely to have negative descriptors included in the patient’s EHR than inpatient encounters. They theorize this may result from inpatient settings being inherently more stressful, thereby increasing the risk of doctors using stereotypes as “cognitive shortcuts.”

They also found that race-based differences in the use of negative descriptors narrowed after March 1, 2020. They theorize this was due to the stark racial differences in care and outcomes highlighted by the COVID-19 pandemic, and the pandemic’s overlap with “a historically defining moment of national response to racialized state violence” created by the killings of George Floyd and other Black Americans.

“These social pressures may have sensitized providers to racism and increased empathy for the experiences of racially minoritized communities,” they note.

Fixing the problem, the authors say, will require medical institutions to better address the issue of implicit racial bias among providers. They cite the example of a physician’s use of the term “aggressive” as reflecting the physician’s personal bias regarding Black men. Once such a negative label becomes part of the patient’s record, “it potentially affects the perceptions and decisions of future providers regardless of whether future providers hold a bias about Black men being aggressive,” they note.

They also recommend that regulatory bodies, such as the Accreditation Council for Graduate Medical Education, develop specific recommendations for the use of non-stigmatizing, patient-centered language to prevent the transmission of bias.

The need is especially important, they say, in light of the OpenNotes policies medical institutions are adopting, which allow patients full access to their EHRs, including chart notes. Without paying attention to the language used to describe patients, they risk “harming the patient-provider relationship with downstream effects on patient satisfaction, trust, and even potential litigation.”

The study, “Negative Patient Descriptors” Documenting Racial Bias In The Electronic Health Record” appears in the February, 2022 issue of 

Articles

Clinicians need to avoid negative terms in describing patients

The Effect of Electronic Health Record Notes on Racial Bias

N95 and KN95 masks are the most effective in preventing the spread of COVID-19, according to 

 from the Centers for Disease Control and Prevention (CDC). At the same time, the agency continues to urge Americans to consistently use the most protective type of masking available so long as it’s comfortable and will be worn consistently.

In its latest guidance, posted on its website on January 14, the CDC ranks different types of 

 according to the level of protection they provide. “Loosely woven cloth products provide the least protection, layered finely woven products offer more protection, well-fitting disposable surgical masks and KN95s offer even more protection, and well-fitting NIOSH [National Institute for Occupational Safety and Health]-approved respirators (including N95s) offer the highest level of protection,” the guidance states.

But regardless of the type of mask chosen, the CDC adds, it should fit closely on the face and be comfortable enough when worn correctly (covering the nose and mouth) that it can be used when needed.

The updated guidance also explains the difference between masks and respirators. Masks are designed primarily to contain droplets that the wearer sneezes, breathes or coughs out, while also offering some protection from viruses spread by others.

Respirators are meant to provide protection by filtering the air and fitting closely on the face to filter out particles, but they also have some ability to contain droplets the wearer emits. “A respirator has better filtration, and if worn properly the whole time it is in use, can provide a higher level of protection than a cloth or procedural mask,” according to the guidance.

Given the greater protection respirators afford, the CDC says they “may be considered in certain situations and by certain people when greater protection may be needed or desired.” These include:

When caring for someone who is sick with COVID-19

If a person is at increased risk for severe illness, such as those who are immunocompromised, are over 65, or have certain underlying medical conditions

Working in a job that requires interacting with large numbers of the public particularly when not everyone is 

When using public transportation, such as buses, planes and trains

In crowded settings where physical distancing isn’t possible

Not being up-to-date on COVID-19 vaccinations

In a statement announcing the updates the CDC said they “reflect the science on masking, including what we have learned in the past two years, and will provide people the information they need to improve how well their 

 them. We will continue to share the science of masking as it becomes available.”

This article was originally published by Medical Economics.

With increased infectivity of Omicron, the CDC has updated the guidance on the best mask types to use.

Mask Updates: CDC Recommends N95 and KN95 

With the COVID-19 pandemic reaching an unprecedented crescendo and pediatric cases continuing to become more prominent with each new variant of the disease, an understanding of how many pediatric cases that initially present and receive testing in an emergency department experience a severe outcome or death is more important than ever. A 

 aims to find the proportion of pediatric patients who experience such outcomes within 14 days.

Investigators performed a prospective cohort study with 14-day follow-up that enrolled participants between March 2020 and June 2021. They included children and adolescents aged younger than 18 years who were tested for COVID-19 infection at an emergency department in 10 countries: Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Infection was confirmed via a polymerase chain reaction test. Severe outcomes were either the occurrence of a complication such as encephalitis or cardiac arrest or the performance of an intervention linked to a severe occurrence such as chest drainage or positive pressure ventilation, as well as death.

There were 3221 patients included in the study, with 2007 coming from the United States and 484 self-reporting a chronic illness. The median age of the cohort was 3 years. Following 14 days of follow-up, 735 children required hospitalization; 107 recorded severe outcomes; and 4 children had died. Investigators noted that there were several characteristic that were linked to severe outcomes, including being aged 5 to 18 years (age 5 to <10 years vs <1 year: odds ratio [OR], 1.60 [95% CI, 1.09-2.34]; age 10 to <18 years vs <1 year: OR, 2.39 [95% CI 1.38-4.14]), having a self-reported chronic illness (OR, 2.34 [95% CI, 1.59-3.44]), prior episode of pneumonia (OR, 3.15 [95% CI, 1.83-5.42]), symptoms starting 4 to 7 days prior to seeking ED care (vs starting 0-3 days before seeking care: OR, 2.22 [95% CI, 1.29-3.82]), and country (eg, Canada vs US: OR, 0.11 [95% CI, 0.05-0.23]; Costa Rica vs US: OR, 1.76 [95% CI, 1.05-2.96]; Spain vs US: OR, 0.51 [95% CI, 0.27-0.98]). In a subcohort of patients who were sent home from the emergency department after being tested and completed the 14 days of follow-up, 50 were subsequently hospitalized and 12 had severe outcomes.

The investigators concluded that about 3% of pediatric patients who tested positive for COVID-19 in the emergency department had severe outcomes within 2 weeks of their initial visit. The risk was much less for children who were sent home from the emergency department than among those who were kept in the hospital. The risk factors noted such as age and underlying chronic illness could be useful when determining a patient’s clinical care.

This article was originally published on 

Funk A, Florin T, Kupperman N, et al. Outcomes of SARS-CoV-2–positive youths tested in emergency departments: the global PERN–COVID-19 study. 

. 2022;5(1):e2142322. doi:10.1001/jamanetworkopen.2021.42322

A global study examines how often severe outcomes occur within 14 days of a positive COVID-19 test occurring in an emergency department (ED).

Severe COVID-19 in Children: Study

 used in the U.S. lose some of their ability to prevent breakthrough infections over time, but they remain highly effective at preventing hospitalizations and deaths, a new study finds.

The study, a collaboration between the University of North Carolina-Chapel Hill and the North Carolina Department of Health and Human Services, sought to determine whether COVID-19 breakthrough infections are the result of waning immunity provided by vaccines or the greater transmissibility of the disease’s variants.

To find out, researchers looked at vaccination histories and health outcomes of 10.6 million North Carolina residents who received either the Pfizer, Moderna or Johnson & Johnson vaccine between December 2020 and September 2021. The data did not include outcomes from the omicron variant, which emerged after the study concluded. Results were published in the 

The researchers found that the mRNA Pfizer and Moderna vaccines, both of which require two doses, were 95% effective at lowering the risk of COVID-19 two months after the first dose. After seven months the Moderna vaccine dropped to 80% effectiveness, while the Pfizer vaccine was 67% effective. The effectiveness of both vaccines dropped significantly during June and July, when the COVID-19 Delta variant was at its height in the state.

The Johnson & Johnson adenovirus vaccine, which requires a single dose, was 75% effective after one month and 60% effective after five months. Based on these findings, the authors conclude that the reduced protection against COVID-19 infection was due to both declining immunity and the emergence of the delta variant.

However, all three vaccines have been more effective at preventing hospitalizations due to severe COVID-19. 

 reached peak effectiveness of 96% at two months and was about 90% after seven months.

Effectiveness of the Moderna vaccine was 97% and 94%, respectively, at the same points. The Johnson & Johnson vaccine peaked at 86% effectiveness at two months and was higher than 80% through six months. All three vaccines were more effective against death than hospitalization.

“The primary takeaway message from our study is that unvaccinated people should get vaccinated right away,” Danyu Lin, PhD, professor of biostatistics at the UNC Gillings School of Global Public Health said in an accompanying news release. “The results of our study also underscore the importance of booster shots, especially for older adults.”

This article was originally posted by Medical Economics.

But protection against hospitalization and death remain strong.

Study: Waning Antibody Protection May Increase Breakthrough Omicron Infection Rates

 pandemic, patients’ initial satisfaction with some forms of 

 is starting to wane, a new survey finds.

The survey by Rock Health, a health care advisory, investment and research firm, is part of an ongoing study of consumers’ use of telemedicine and attitudes towards it. It found that in 2021 43% of respondents were satisfied with the care they received via live video calls—the most widely-used form of telemedicine this year--compared to prior in-person care interactions. In 2020 53% of 2020’s respondents said they were satisfied with live video calls as a form of care.

/websites and text messaging declined, although by lesser margins than live 

 On the other hand, satisfaction with live phone calls and picture/video modalities rose, the latter from 41% to 54%. Satisfaction with email was unchanged.

The authors offer two possible explanations for declining contentment with live video calls as a form of care delivery. The first is that the sense of satisfaction patients felt for having any form of health care during much of 2020, when in-person visits weren’t possible, has faded in 2021. They note that a similar trend has occurred among physicians, 58% of whom view 

 more positively now than before the pandemic, compared to 64% of those surveyed in 2020.

A second possibility lies in the changing nature of why people used telemedicine. In 2020 the largest category of users of live video calls among survey respondents—33%--were people with a medical emergency. Among that group, 77% reported higher levels of satisfaction with virtual interactions than with in-person care.

In 2021, however, the single biggest use for live video telemedicine (32% of survey respondents) was for minor illnesses, and only 37% of those users reported greater satisfaction compared to in-person care. In short, the authors say, “satisfaction with telemedicine as a convenient alternative may be lower than telemedicine as a necessary access point.”

The survey also found less telemedicine use among respondents identifying as white-only than other racial and ethnic groups. In 2021 70% of white-only respondents said they used telemedicine, compared to 87% of Hawaiian Native and/or Pacific Islander respondents, 79% among both Black and American Indian and/or Alaska native respondents, 78% of Asians and 73% of Hispanics.

The authors acknowledge that since the survey was conducted in English via computer, Black and Hispanic adults may be underrepresented since they are less likely than white adults to own a desktop or laptop computer or have home high-speed internet. Even so, they say, their findings are consistent with results of a 2020 Pew study showing that Black, Hispanic and other non-white adults were more likely to use telemedicine than were white adults.

The study, “Consumer adoption of telemedicine in 2021,” is available on the website of 

This article was originally published by publication Medical Economics.

Two possible explanations for declining contentment with live video calls as a form of care delivery.

Preference for Telehealth in Decline 

 (CGMs) less than white beneficiaries, and the gap is widening, according to the Endocrine Society.

In a news release, the Society says a new study published in its 

Journal of Clinical Endocrinology & Metabolism

 finds that the prevalence of insulin pump use for Black beneficiaries with Type 1 diabetes increased from 3.9% to 4.6% between 2017 and 2019. But use of insulin pumps among white beneficiaries increased from 14% to 18.2% during that period.

In addition, the release says, about 25% of white Medicare beneficiaries were using CGMs in 2019, compared to 12% of Black beneficiaries, and the gap had widened since 2017. Both insulin pumps and CSGs are regarded as important tools for controlling diabetes.

The study’s authors used data from Medicare’s

 database to determine the prevalence of diabetes technology use by race and ethnicity. They found that while CGM and insulin pump use grew among all groups during the period under study, the increase was greatest among white beneficiaries.

“Previous studies in non-Medicare beneficiaries point to socio-economic status as the key driver of unequal adoption of diabetes technology, but our study shows many other contributing factors,” Robert Vigersky, M.D., chief medical officer of medical device manufacturer Medtronic Diabetes says in the release. Medtronic Diabetes funded the research.

The other factors he cites include unconscious bias among health care providers who may think people of color aren’t able to use the technologies, cultural barriers, low health literacy and limited access to endocrinologists. “We need to address the social determinants of health, including race and ethnicity, before all aspects of diabetes care become more equitable,” said Vigersky,

“Inequity in Adoption of Advanced Diabetes Technologies Among Medicare Fee-for-Service Beneficiaries,” was published online, ahead of print by the Endocrine Society.

This article originally appeared on Medical Economics.

The prevalence of insulin pump use for Black beneficiaries increased from 3.9% to 4.6% between 2017 and 2019.