Implicit Bias And Unintentional Harm In Vascular Care: The Case For Intervention
Authors: Kalbaugh Corey A. , Beidelman Erika T. , Howard Kerry A. , Witrick Brian , Clark Ashley , McGinigle Katharine L. , Minc Samantha , Alabi Olamide , Hicks Caitlin W. , Gonzalez Andrew A. , Cené Crystal W. , Cykert Samuel 
Published: February 2024

ABSTRACTIntroductionImplicit (or unconscious) bias may influence physician treatment decisions and contribute to Black-White health disparities. While implicit bias has been linked with low quality care via clinical vignettes, some worry that these studies are not representative of the ‘real world.’ There is limited data that has attempted to link implicit bias with actual care delivery and outcomes. We sought to understand if implicit bias is associated with potentially harmful surgical treatment selection in a cohort of patients with peripheral artery disease (PAD)-related claudication undergoing below-knee lower extremity revascularization as captured in a ‘real world’ procedural registry.MethodsWe invited vascular specialists from the Vascular Quality Initiative (VQI) to take the race Implicit Association Test (IAT). The IAT asks participants to associate images of Black and White Americans with either positive or negative attributes. Based on reaction time differences across sequential tests, participants were grouped into race-based implicit bias categories: pro-White bias, no bias, or pro-Black bias. Our provider-level implicit bias results were linked to patient-level registry data of peripheral revascularization procedures performed for claudication. We measured the adjusted odds of performance of below knee procedures by specialist implicit bias and patient race via mixed effects logistic regression models. We assessed implicit bias as a moderator of the association of below-knee procedures and patient race with 1-yr amputation.Results218 vascular specialists in the United States completed the IAT and 157 (72%) had a pro-White bias. Black patients treated by a physician with pro-White bias had a 74% increase in the odds of receiving a below-knee procedure compared to the total sample (aOR: 1.74, 95% CI: 1.33-2.15). When treated by a specialist with pro-White bias, Black patients had 3 times the odds of 1-yr amputation – regardless of anatomic location treated – compared to White patients (aOR: 3.04, 95% CI: 1.68-5.51). Conversely, Black patients treated by a specialist with no bias had similar odds of a below-knee procedure (aOR: 0.99, 95% CI: 0.67-1.30) and 1-year amputation (aOR: 1.31, 95% CI: 0.35-4.96) as the full patient sample.ConclusionsImplicit bias is associated with potentially harmful below-knee procedures for Black patients and contributes to Black-White outcome disparities in the United States. These results suggest the need for system-level interventions that transparently identify and warn of procedures not aligned with best practices to reduce the negative effect of implicit bias.Clinical PerspectiveWhat is new?Pro-White bias is associated with low-value care for Black patients.Black patients treated by physicians with pro-White implicit preferences also had worse 1-year amputation rates.We found little race-based variation in treatment decisions for below-knee revascularization procedures among physicians with no implicit bias as measured by the IAT.What are the clinical implications?Physicians who treat vascular diseases consider their own practices and where they may be falling short of standards, particularly for their Black patients.Health care leaders must begin to evaluate how and why their own health care systems make it possible for practitioners’ unconscious biases to negatively impact care.Policy changes that enhance payment for evidence-based procedures and reduce payment for potentially harmful procedures should be considered.