1. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation What is “Heads Up?” 2007 AAPA Committee on Diversity Project2007 AAPA Committee on Diversity Project 90 days in University of Washington Shuttles90 days in University of Washington Shuttles 3 signs, each up on 5 buses for one month3 signs, each up on 5 buses for one month

2. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation

3. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation What is Heads Up? Initial Project Goals: 1.Engage Clinicians and Clinicians in Training 2.Spotlight Racial Health Disparities 3.Create focus on Implicit Bias/Stereotyping

4. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation What is Heads Up? Transitioned now to CME moduleTransitioned now to CME module Creation of PA School Curriculum ModuleCreation of PA School Curriculum Module

5. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Define “Racial Health Disparities” Even with the same access to care, racial and ethnic minorities receive poorer care than white patients (IOM’s “Unequal Treatment,” 2003)

6. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation IOM’s 2003 Unequal Treatment Landmark review of data, indicating consistent disparities in care: “Racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access-related factors, such as patient's insurance status and income, are controlled." “Racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access-related factors, such as patient's insurance status and income, are controlled." Unequal Treatment, page 1

7. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Disparities in Cardiovascular Care African Americans 28% more likely to die than white Americans from cardiovascular disease, yet African Americans referred less frequently for cardiac catheterizationAfrican Americans 28% more likely to die than white Americans from cardiovascular disease, yet African Americans referred less frequently for cardiac catheterization Whites being treated in emergency rooms for chest pain more likely to receive cardiac catheterization than African AmericansWhites being treated in emergency rooms for chest pain more likely to receive cardiac catheterization than African Americans Likelihood of having hospital-based cardiac procedures consistently greater for whites than for African AmericansLikelihood of having hospital-based cardiac procedures consistently greater for whites than for African Americanshttp://www.aapa.org/clinissues/disparitiestables.html#table1

8. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Disparities in Cardiovascular Care Likelihood of having cardiac procedure nearly three times greater for whites than for African AmericansLikelihood of having cardiac procedure nearly three times greater for whites than for African Americans African Americans and Hispanics received less-frequent coronary artery bypass grafts than whites with similar diagnosesAfrican Americans and Hispanics received less-frequent coronary artery bypass grafts than whites with similar diagnoses Fewer non-whites underwent cardiac catheterization when meeting initiation criteriaFewer non-whites underwent cardiac catheterization when meeting initiation criteriahttp://www.aapa.org/clinissues/disparitiestables.html#table1

9. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Disparities in Cardiovascular Care In patients with acute myocardial infarction, African Americans less likely than whites to receive thrombolytic therapy, coronary arteriography and coronary artery bypass surgeryIn patients with acute myocardial infarction, African Americans less likely than whites to receive thrombolytic therapy, coronary arteriography and coronary artery bypass surgery In patients discharged from hospital stays after definite or possible myocardial infarctions, Mexican Americans received significantly fewer medications than whitesIn patients discharged from hospital stays after definite or possible myocardial infarctions, Mexican Americans received significantly fewer medications than whiteshttp://www.aapa.org/clinissues/disparitiestables.html#table1

10. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Racial Disparities in Treatment of Pain racial and ethnic disparities in pain perception, assessment found in all settingsracial and ethnic disparities in pain perception, assessment found in all settings postoperative, emergency room, across all types of pain (acute, cancer, chronic nonmalignant)postoperative, emergency room, across all types of pain (acute, cancer, chronic nonmalignant)

11. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Racial Disparities in Treatment of Pain Disparities persist after controlling for comorbidities, insurance status, treatment, patient preferences, and access to careDisparities persist after controlling for comorbidities, insurance status, treatment, patient preferences, and access to care

12. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation “Implicit Bias” and “Unconscious Stereotyping” Research indicates: Implicit biases are pervasive.Implicit biases are pervasive. People are often unaware of their implicit biasesPeople are often unaware of their implicit biases Ordinary people harbor negative associations in relation to various groupsOrdinary people harbor negative associations in relation to various groups

13. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation “Implicit Bias” and “Unconscious Stereotyping” Implicit biases predict behaviorImplicit biases predict behavior People differ in levels of implicit biasPeople differ in levels of implicit bias

14. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Implicit Association Test (IAT) “Project Implicit”: network of laboratories, technicians, and research scientists at Harvard University, the University of Washington, and the University of Virginia“Project Implicit”: network of laboratories, technicians, and research scientists at Harvard University, the University of Washington, and the University of Virginia Initially launched as a demonstration website in 1998 at Yale University, and began to function fully as a research enterprise following a grant from the National Institute of Mental Health in 2003Initially launched as a demonstration website in 1998 at Yale University, and began to function fully as a research enterprise following a grant from the National Institute of Mental Health in 2003

15. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Implicit Association Test (IAT) Series of online assessments related to multilple groups (sexual orientation, race, gender, religion)Series of online assessments related to multilple groups (sexual orientation, race, gender, religion) Feedback and assessment results immediateFeedback and assessment results immediate

16. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation

17. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Implicit Bias and Clinical Outcomes Physicians reported no explicit preference for white versus black patientsPhysicians reported no explicit preference for white versus black patients Implicit Association Test (IAT) revealed implicit preference favoring white AmericansImplicit Association Test (IAT) revealed implicit preference favoring white Americans

18. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Implicit Bias and Clinical Outcomes IAT revealed implicit stereotypes of black Americans as less cooperative with medical procedures and less cooperative generallyIAT revealed implicit stereotypes of black Americans as less cooperative with medical procedures and less cooperative generally As physicians’ pro-white implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysisAs physicians’ pro-white implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis

19. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Dual Process Stereotyping Two distinct methods of stereotyping: 1.Automatic stereotyping 2.Goal modified stereotyping Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006

20. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Automatic Stereotyping occurs when stereotypes are automatically activated and influence judgments/behaviors outside of consciousnessoccurs when stereotypes are automatically activated and influence judgments/behaviors outside of consciousness Occur regardless of their relevance to the perceivers’ goalsOccur regardless of their relevance to the perceivers’ goals Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006

21. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Goal Modified Stereotyping More conscious process, done when specific needs of clinician arise (time constraints, filling in gaps in information needed to make complex decisionsMore conscious process, done when specific needs of clinician arise (time constraints, filling in gaps in information needed to make complex decisions Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006

22. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Function of Stereotyping Providers are likely to apply information contained in racial/ethnic stereotypes to interpret symptoms and make decisionsProviders are likely to apply information contained in racial/ethnic stereotypes to interpret symptoms and make decisions Stereotypes likely to be used when stereotypic information is perceived as clinically relevant, and the decision is complexStereotypes likely to be used when stereotypic information is perceived as clinically relevant, and the decision is complex Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006 Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006

23. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Healthy People 2010 Goal II: “… to eliminate health disparities among segments of the population, including differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation.”

24. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Substantial disparities between population groupsSubstantial disparities between population groups Few changes in disparity since the baseline when measuredFew changes in disparity since the baseline when measured Overall, no consistent pattern of change in disparity for any population group (except males)Overall, no consistent pattern of change in disparity for any population group (except males) http://www.cdc.gov/nchs/ppt/duc2006/hallquist_52.ppt#769,1,Midcourse Assessment of Healthy People 2010 Goal II HP 2010 Review in 2006:

25. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Creating Equity Reports tool that allows a clinic/site of care to examine, measure, and address inequalities in the care provided to patients from different cultural backgrounds.tool that allows a clinic/site of care to examine, measure, and address inequalities in the care provided to patients from different cultural backgrounds. it can help identify areas where things are going well and those where there are opportunities for improvementit can help identify areas where things are going well and those where there are opportunities for improvement

26. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Creating Equity Reports can also help with monitoring progress over time toward eliminating inequalitiescan also help with monitoring progress over time toward eliminating inequalities Promotes goal of providing the highest quality of care to all patients, regardless of their race, ethnicity, language, or socioeconomic status, or sexual orientationPromotes goal of providing the highest quality of care to all patients, regardless of their race, ethnicity, language, or socioeconomic status, or sexual orientation

27. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Creating Equity Reports STEPS: pick a process (examples: mammograms, guideline adherence for asthma or diabetes)pick a process (examples: mammograms, guideline adherence for asthma or diabetes) collect data ( who gets them, who doesn’t)collect data ( who gets them, who doesn’t) compare racial and other cultural groupscompare racial and other cultural groups assess disparities, create action plan where disparity notedassess disparities, create action plan where disparity notedhttp://www.massgeneral.org/disparitiessolutions/resources.html

28. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Web and Other Resources Implicit Association Test: https://implicit.harvard.edu/implicit/ https://implicit.harvard.edu/implicit/ Project Implicit Information Page: http://projectimplicit.net/ (Recommended Tests: Race, Arab-Muslim, Gender, Sexuality) http://projectimplicit.net/ (Recommended Tests: Race, Arab-Muslim, Gender, Sexuality) "The Police Officer's Dilemma" http://home.uchicago.edu/~jcorrell/TPOD.html and then click on the very bottom link http://backhand.uchicago.edu/Center/ShooterEffect/

29. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation http://backhand.uchicago.edu/Center/ShooterEffect/

30. Heads Up! A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation Web and Other Resources “Heads Up!” Website: http://www.stop-disparities.org/RESOURCES.html