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African Americans are more likely than members of other racial groups to report perceived discrimination in health care settings, and discrimination is linked to depression. Using data from a randomized controlled trial of pain coping skills training (PCST) for African Americans with osteoarthritis (N=164), we evaluated the interaction between discrimination experiences and experimental condition (PCST or control group) in linear regression models predicting depressive symptoms. There was a significant interaction between personal discrimination and experimental condition on depressive symptoms (interaction term coefficient: b=-3.2, 95% CI [- 6.4, - .02], p=.05). Discrimination was associated with depressive symptoms among those in the control group but not among those who received PCST. Participation in a PCST intervention may have reduced the association between discrimination experiences and depressive symptoms among participants in this sample. Future research should explore whether interventions aimed at teaching coping skills may be effective in ameliorating the harmful mental health effects of perceived discrimination.

The study goal was to determine whether partner's level of unmitigated communion moderated the relation of partner communal coping to patient health. Couples in which one person was recently diagnosed with type 2 diabetes ( n  = 123) were interviewed separately and asked to discuss a diabetes-related problem. Communal coping behavior (from videotaped discussions) interacted with partner communal coping, such that partner communal coping was related to lower patient distress, higher patient self-efficacy, and higher patient medication adherence only when partners scored lower on unmitigated communion. The extent to which perceived emotional responsiveness and overprotective behavior mediated these relations was explored.

Background and Objectives: The general population and most physicians have implicit racial bias against black adults. Pediatricians also have implicit bias against black adults, albeit less than other specialties. There is no published research on the implicit racial attitudes of pediatricians or other physicians toward children. Our objectives were to compare implicit racial bias toward adults versus children among resident physicians working in a pediatric emergency department, and to assess whether bias varied by specialty (pediatrics, emergency medicine, or other), gender, race, age, and year of training., Methods: We measured implicit racial bias of residents before a pediatric emergency department shift using the Adult and Child Race Implicit Association Tests (IATs). Generalized linear models compared Adult and Child IAT scores and determined the association of participant demographics with Adult and Child IAT scores., Results: Among 91 residents, we found moderate pro-white/anti-black bias on both the Adult (mean = 0.49, standard deviation = 0.34) and Child Race IAT (mean = 0.55, standard deviation = 0.37). There was no significant difference between Adult and Child Race IAT scores (difference = 0.06, P = .15). Implicit bias was not associated with resident demographic characteristics, including specialty., Conclusions: This is the first study demonstrating that resident physicians have implicit racial bias against black children, similar to levels of bias against black adults. Bias in our study did not vary by resident demographic characteristics, including specialty, suggesting that pediatric residents are as susceptible as other physicians to implicit bias. Future studies are needed to explore how physicians' implicit attitudes toward parents and children may impact inequities in pediatric health care., (Copyright © 2016 Academic Pediatric Association. All rights reserved.)

There are 2.1 million current military servicemembers and 21 million living veterans in the United States. Although they were healthier upon entering military service compared to the general U.S. population, in the longer term veterans tend to be of equivalent or worse health than civilians. One primary explanation for the veterans' health disparity is poorer health behaviors during or after military service, especially areas of physical activity, nutrition, tobacco, and alcohol. In response, the Department of Defense and Department of Veterans Affairs continue to develop, evaluate, and improve health promotion programs and healthcare services for military and veteran health behavior in an integrated approach. Future research and practice is needed to better understand and promote positive health behavior during key transition periods in the military and veteran life course. Also paramount is implementation and evaluation of existing interventions, programs, and policies across the population using an integrated and person centered approach.

Background: Buprenorphine is a key tool in the management of opioid use disorder, but there are growing concerns about abuse, diversion, and safety. These concerns are amplified for the Department of Veterans Affairs (VA), whose patients may receive care concurrently from multiple prescribers within and outside VA. To illustrate the extent of this challenge, we examined overlapping prescriptions for buprenorphine, opioids, and benzodiazepines among veterans dually enrolled in VA and Medicare Part D., Methods: We constructed a cohort of all veterans dually enrolled in VA and Part D who filled an opioid prescription in 2012. We identified patients who received tablet or film buprenorphine products from either source. We calculated the proportion of buprenorphine recipients with any overlapping prescription (based on days supply) for a nonbuprenorphine opioid or benzodiazepine, focusing on veterans who received overlapping prescriptions from a different system than their buprenorphine prescription (Part D buprenorphine recipients receiving overlapping opioids or benzodiazepines from VA and vice versa)., Results: There were 1790 dually enrolled veterans with buprenorphine prescriptions, including 760 (43%) from VA and 1091 (61%) from Part D (61 veterans with buprenorphine from both systems were included in each group). Among VA buprenorphine recipients, 199 (26%) received an overlapping opioid prescription and 11 (1%) received an overlapping benzodiazepine prescription from Part D. Among Part D buprenorphine recipients, 208 (19%) received an overlapping opioid prescription and 178 (16%) received an overlapping benzodiazepine prescription from VA. Among VA and Part D buprenorphine recipients with cross-system opioid overlap, 25% (49/199) and 35% (72/208), respectively, had >90 days of overlap., Conclusions: Many buprenorphine recipients receive overlapping prescriptions for opioids and benzodiazepines from a different health care system than the one in which their buprenorphine was filled. These findings highlight a previously undocumented safety risk for veterans dually enrolled in VA and Medicare.

Background: Patient-Centered Medical Homes (PCMH) may be effective in managing care for racial/ethnic minorities with mental health and/or substance use disorders (MHSUDs). How such patients experience care in PCMH settings is relatively unknown., Objective: We aimed to examine racial/ethnic differences in experiences with primary care in PCMH settings among Veterans with MHSUDs., Design: We used multinomial regression methods to estimate racial/ethnic differences in PCMH experiences reported on a 2013 national survey of Veterans Affairs patients., Particpants: Veterans with past-year MHSUD diagnoses (n = 65,930; 67 % White, 20 % Black, 11 % Hispanic, 1 % American Indian/Alaska Native[AI/AN], and 1 % Asian/Pacific Island[A/PI])., Main Measures: Positive and negative experiences from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) PCMH Survey., Results: Veterans with MHSUDs reported the lowest frequency of positive experiences with access (22 %) and the highest frequency of negative experiences with self-management support (30 %) and comprehensiveness (16 %). Racial/ethnic differences (as compared to Whites) were observed in all seven healthcare domains (p values < 0.05). With access, Blacks and Hispanics reported more negative (Risk Differences [RDs] = 2 .0;3.6) and fewer positive (RDs = -2 .3;-2.3) experiences, while AI/ANs reported more negative experiences (RD = 5.7). In communication, Blacks reported fewer negative experiences (RD = -1.3); AI/ANs reported more negative (RD = 3.6) experiences; and AI/ANs and APIs reported fewer positive (RD = -6.5, -6.7) experiences. With office staff, Hispanics reported fewer positive experiences (RDs = -3.0); AI/ANs and A/PIs reported more negative experiences (RDs =  3.4; 3.7). For comprehensiveness, Blacks reported more positive experiences (RD = 3.6), and Hispanics reported more negative experiences (RD = 2.7). Both Blacks and Hispanics reported more positive (RDs = 2.3; 4.2) and fewer negative (RDs = -1.8; -1.9) provider ratings, and more positive experiences with decision making (RDs = 2.4; 3.0). Blacks reported more positive (RD = 3.9) and fewer negative (RD = -5.1) experiences with self-management support., Conclusions: In a national sample of Veterans with MHSUDs, potential deficiencies were observed in access, self-management support, and comprehensiveness. Racial/ethnic minorities reported worse experiences than Whites with access, comprehensiveness, communication, and office staff helpfulness/courtesy., Competing Interests: The authors declare that they do not have a conflict of interest.

Objective: To examine the relation between daily diary reports of diabetes-specific social interactions to patient and partner mood and patient self-care behaviors, and whether relations are moderated by unmitigated communion., Method: Participants were 70 couples in which 1 person had been diagnosed with Type 2 diabetes in the past 3 years. They were interviewed in-person at baseline and completed daily diary reports on an iPad. Daily diary questionnaires measured support, mood, and self-care behavior (patients only). Unmitigated communion, a personality trait characterized by an overinvolvement in others to the exclusion of the self, was measured at baseline., Results: Multilevel statistical modeling revealed that daily fluctuations in partner emotional support were related to daily fluctuations in happy mood, more exercise, and dietary compliance. Partner controlling behavior was related to poor mood but was unrelated to self-care. Relations of support and controlling behavior to mood were strongest for individuals high (vs. low) in unmitigated communion., Conclusion: Patients newly diagnosed with Type 2 diabetes who felt understood and cared for by partners reported a better mood and were more likely to take care of themselves on a daily basis, whereas patients whose partners were controlling on a daily basis reported poorer mood. Patients characterized by unmitigated communion were most affected by partner supportive and unsupportive behavior. (PsycINFO Database Record, ((c) 2016 APA, all rights reserved).)

Objectives: The emergency department (ED) is characterized by stressors (e.g., fatigue, stress, time pressure, and complex decision-making) that can pose challenges to delivering high-quality, equitable care. Although it has been suggested that characteristics of the ED may exacerbate reliance on cognitive heuristics, no research has directly investigated whether stressors in the ED impact physician racial bias, a common heuristic. We seek to determine if physicians have different levels of implicit racial bias post-ED shift versus preshift and to examine associations between demographics and cognitive stressors with bias., Methods: This repeated-measures study of resident physicians in a pediatric ED used electronic pre- and postshift assessments of implicit racial bias, demographics, and cognitive stressors. Implicit bias was measured using the Race Implicit Association Test (IAT). Linear regression models compared differences in IAT scores pre- to postshift and determined associations between participant demographics and cognitive stressors with postshift IAT and pre- to postshift difference scores., Results: Participants (n = 91) displayed moderate prowhite/antiblack bias on preshift (mean ± SD = 0.50 ± 0.34, d = 1.48) and postshift (mean ± SD = 0.55 ± 0.39, d = 1.40) IAT scores. Overall, IAT scores did not differ preshift to postshift (mean increase = 0.05, 95% CI = -0.02 to 0.14, d = 0.13). Subanalyses revealed increased pre- to postshift bias among participants working when the ED was more overcrowded (mean increase = 0.09, 95% CI = 0.01 to 0.17, d = 0.24) and among those caring for >10 patients (mean increase = 0.17, 95% CI = 0.05 to 0.27, d = 0.47). Residents' demographics (including specialty), fatigue, busyness, stressfulness, and number of shifts were not associated with postshift IAT or difference scores. In multivariable models, ED overcrowding was associated with greater postshift bias (coefficient = 0.11 per 1 unit of NEDOCS score, SE = 0.05, 95% CI = 0.00 to 0.21)., Conclusions: While resident implicit bias remained stable overall preshift to postshift, cognitive stressors (overcrowding and patient load) were associated with increased implicit bias. Physicians in the ED should be aware of how cognitive stressors may exacerbate implicit racial bias., (© 2016 by the Society for Academic Emergency Medicine.)

Objectives: Racial minorities experience lower rates of alcohol treatment completion than whites. Treatment satisfaction is an important factor in alcohol treatment retention, yet few studies have explored the satisfaction of racial minorities while in treatment. This study examined racial differences in addiction treatment satisfaction and explored factors that might mediate or moderate racial differences in satisfaction., Methods: We surveyed non-Hispanic black and non-Hispanic white veterans with an alcohol-related diagnosis about addiction treatment services at a large Veterans Affairs medical center. Treatment satisfaction was measured using the 8-item Client Satisfaction Questionnaire, dichotomized as low versus non-low satisfaction in analyses. The χ and logistic regression methods were used to test for associations of race and sociodemographic characteristics with treatment satisfaction., Results: Among 271 black and 304 white veterans with an alcohol-related diagnosis, race was not statistically associated with treatment satisfaction in bivariate analyses (P > 0.05). However, we identified significant interactions of race with mental health diagnoses in predicting treatment satisfaction in multivariable analyses (adj odds ratio = 0.55; 95% confidence interval [CI] = 0.39-0.78). In post hoc comparisons among veterans with zero mental health diagnoses, black veterans had a greater probability of reporting low satisfaction than whites (marginal difference = 0.13; 95% CI = 0.04-0.22). In veterans with 4 or more diagnoses, whites had a greater probability than blacks of reporting low satisfaction (marginal difference = 0.28, 95% CI = 0.10-0.46). Regardless of race, past homelessness was associated with low satisfaction (adj odds ratio = 2.09; 95% CI = 1.19-3.67)., Conclusions: Racial minorities, veterans with unstable housing, and white veterans with co-occurring mental health disorders may be at risk of experiencing low treatment satisfaction.

Background: Racial disparities in the clinical outcomes of systemic lupus erythematosus (SLE) exist. Perceived racial discrimination may contribute to disparities in health., Objectives: To determine if perceived racism in healthcare differs by race among patients with SLE and to evaluate its contribution to racial disparities in SLE-related outcomes., Methods: 163 African-American (AA) and 180 white (WH) patients with SLE were enrolled. Structured interviews and chart reviews were done to determine perceptions of racism, SLE-related outcomes (Systemic Lupus International Collaborating Clinics (SLICC) Damage Index, SLE Disease Activity, Center for Epidemiologic Studies-Depression (CES-D)), and other variables that may affect perceptions of racism. Serial hierarchical multivariable logistic regression models were conducted. Race-stratified analyses were also performed., Results: 56.0% of AA patients compared with 32.8% of WH patients had high perceptions of discrimination in healthcare (p<0.001). This difference remained (OR 4.75 (95% CI 2.41 to 8.68)) after adjustment for background, identity and healthcare experiences. Female gender (p=0.012) and lower trust in physicians (p<0.001) were also associated with high perceived racism. The odds of having greater disease damage (SLICC damage index ≥2) were higher in AA patients than in WH patients (crude OR 1.55 (95% CI 1.01 to 2.38)). The odds of having moderate to severe depression (CES-D ≥17) were also higher in AA patients than in WH patients (crude OR 1.94 (95% CI 1.26 to 2.98)). When adjusted for sociodemographic and clinical characteristics, racial disparities in disease damage and depression were no longer significant. Among AA patients, higher perceived racism was associated with having moderate to severe depression (adjusted OR 1.23 (95% CI 1.05 to 1.43)) even after adjusting for sociodemographic and clinical variables., Conclusions: Perceptions of racism in healthcare were more common in AA patients than in WH patients with SLE and were associated with depression. Interventions aimed at modifiable factors (eg, trust in providers) may reduce higher perceptions of race-based discrimination in SLE.

Context: Despite evidence that healthcare providers have implicit biases that can impact clinical interactions and decisions, implicit bias among physicians caring for individuals with spinal cord injury (SCI) has not been examined., Objective: Conduct a pilot study to examine implicit racial bias of SCI physicians and its association with functioning and wellbeing for individuals with SCI., Design: Combined data from cross-sectional surveys of individuals with SCI and their SCI physicians., Setting: Four national SCI Model Systems sites., Participants: Individuals with SCI (N = 162) and their SCI physicians (N = 14)., Outcome Measures: SCI physicians completed online surveys measuring implicit racial (pro-white/anti-black) bias. Individuals with SCI completed questionnaires assessing mobility, physical independence, occupational functioning, social integration, self-reported health, depression, and life satisfaction. We used multilevel regression analyses to examine the associations of physician bias and outcomes of individuals with SCI., Results: Physicians had a mean bias score of 0.62 (SD = 0.35), indicating a strong pro-white/anti-black bias. Greater physician bias was associated with disability among individuals with SCI in the domain of social integration (odds ratio = 4.80, 95% confidence interval (CI) = 1.44, 16.04), as well as higher depression (B = 3.24, 95% CI = 1.06, 5.41) and lower life satisfaction (B = -4.54, 95% CI= -8.79, -0.28)., Conclusion: This pilot study indicates that SCI providers are susceptible to implicit racial bias and provides preliminary evidence that greater implicit racial bias of physicians is associated with poorer psychosocial health outcomes for individuals with SCI. It demonstrates the feasibility of studying implicit bias among SCI providers and provides guidance for future research on physician bias and patient outcomes.

Background: Nearly every U.S. hospital publicly reports its performance on quality measures for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia. Because performance rates are not reported according to race or ethnic group, it is unclear whether improvements in equity of care have accompanied aggregate improvements in health care quality over time., Methods: We assessed performance rates for quality measures covering three conditions (six measures for acute myocardial infarction, four for heart failure, and seven for pneumonia). These rates, adjusted for patient- and hospital-level covariates, were compared among non-Hispanic white, non-Hispanic black, and Hispanic patients who received care between 2005 and 2010 in acute care hospitals throughout the United States., Results: Adjusted performance rates for the 17 quality measures improved by 3.4 to 57.6 percentage points between 2005 and 2010 for white, black, and Hispanic adults (P<0.001 for all comparisons). In 2005, as compared with adjusted performance rates for white patients, adjusted performance rates were more than 5 percentage points lower for black patients on 3 measures (range of differences, 12.3 to 14.2) and for Hispanic patients on 6 measures (5.6 to 14.5). Gaps decreased significantly on all 9 of these measures between 2005 and 2010, with adjusted changes for differences between white patients and black patients ranging from -8.5 to -11.8 percentage points and from -6.2 to -15.1 percentage points for differences between white patients and Hispanic patients. Decreasing differences according to race or ethnic group were attributable to more equitable care for white patients and minority patients treated in the same hospital, as well as to greater performance improvements among hospitals that disproportionately serve minority patients., Conclusions: Improved performance on quality measures for white, black, and Hispanic adults hospitalized for acute myocardial infarction, heart failure, or pneumonia was accompanied by increased racial and ethnic equity in performance rates both within and among U.S. hospitals. (Funded by the Centers for Medicare and Medicaid Services and the Veterans Affairs Health Services Research and Development Career Development Program.).

Importance: Nearly every US acute care hospital reports publicly on adherence to recommended processes of care for patients hospitalized with pneumonia. However, it remains uncertain how much performance of these process measures has improved over time or whether performance is associated with superior patient outcomes., Objectives: To describe trends in processes of care, mortality, and readmission for elderly patients hospitalized for pneumonia and to assess the independent associations between processes and outcomes of care., Design, Setting, and Participants: Retrospective cohort study conducted from January 1, 2006, to December 31, 2010, at 4740 US acute care hospitals. The cohort included 1 818 979 cases of pneumonia in elderly (≥65 years), Medicare fee-for-service patients who were eligible for at least 1 of 7 pneumonia inpatient processes of care tracked by the Centers for Medicare & Medicaid Services (CMS)., Main Outcomes and Measures: Annual performance rates for 7 pneumonia processes of care and an all-or-none composite of these measures; and 30-day, all-cause mortality and hospital readmission, adjusted for patient and hospital characteristics., Results: Adjusted annual performance rates for all 7 CMS processes of care (expressed in percentage points per year) increased significantly from 2006 to 2010, ranging from 1.02 for antibiotic initiation within 6 hours to 5.30 for influenza vaccination (P < .001). All 7 measures were performed in more than 92% of eligible cases in 2010. The all-or-none composite demonstrated the largest adjusted relative increase over time (6.87 percentage points per year; P < .001) and was achieved in 87.4% of cases in 2010. Adjusted annual mortality decreased by 0.09 percentage points per year (P < .001), driven primarily by decreasing mortality in the subgroup not treated in the intensive care unit (ICU) (-0.18 percentage points per year; P < .001). Adjusted annual readmission rates decreased significantly by 0.25 percentage points per year (P < .001). All 7 processes of care were independently associated with reduced 30-day mortality, and 5 were associated with reduced 30-day readmission., Conclusions and Relevance: Performance of processes of care for elderly patients hospitalized for pneumonia improved substantially from 2006 to 2010. Adjusted 30-day mortality declined slightly over time primarily owing to improved survival among non-ICU patients, and all individual processes of care were independently associated with reduced mortality.

Background: There is evidence that Black patients may experience stereotype threat--apprehension about being negatively stereotyped--in healthcare settings, which might adversely affect their behavior in clinical encounters. Recent studies conducted outside of healthcare have shown that a brief self-affirmation intervention, in which individuals are asked to focus on and affirm their valued characteristics and sources of personal pride, can reduce the negative effects of stereotype threat on academic performance and on interpersonal communication., Methods: This randomised controlled trial examined whether a self-affirmation (SA) intervention would decrease the negative effects of stereotype threat (negative mood, lower state self-esteem, greater perceptions of racial discrimination) and increase communication self-efficacy among Black primary care patients. Self-affirmation was induced by having patients complete a 32-item values affirmation questionnaire., Results: Patients in the SA condition had lower levels of performance self-esteem and social self-esteem than patients in the control. There were no differences between the SA and the control groups on negative mood, communication self-efficacy, and perceptions of discrimination., Conclusions: Our SA intervention lowered state self-esteem among Black patients. Future research is needed to determine the type of SA task that is most effective for this population., (Published 2013. This article is a U.S. Government work and is in the public domain in the USA.)

Unlabelled: Inducing temporary positive states reduces pain and increases pain tolerance in laboratory studies. We tested whether completing positive activities in one's daily life produces long-term reductions in self-reported bodily pain in a randomized controlled trial of an online positive activities intervention. Participants recruited via the Web were randomly assigned to complete 0, 2, 4, or 6 positive activities administered online over a 6-week period. Follow-up assessments were collected at the end of 6 weeks and at 1, 3, and 6 months postintervention. We used linear mixed effects models to examine whether the intervention reduced pain over time among those who had a score <67 on the bodily pain subscale of the Short Form-36 at baseline (N = 417; pain scores range from 0 to 100; higher scores indicate less pain). Mean pain scores improved from baseline to 6 months in the 2-activity (55.7 to 67.4), 4-activity (54.2 to 71.0), and 6-activity (50.9 to 67.9) groups. Improvements were significantly greater (P < .05) in the 4-activity and 6-activity groups than in the 0-activity control group (54.1 to 62.2) in unadjusted and adjusted models. This study suggests that positive activities administered online can reduce bodily pain in adults with at least mild to moderate baseline pain., Perspective: This study demonstrates that teaching people simple positive activities can decrease reported levels of bodily pain; moreover, these activities can be administered over the internet, a potential avenue for broadly disseminating health interventions at relatively low costs and with high sustainability., (Published by Elsevier Inc.)

Background: Few studies have assessed sex or racial/ethnic differences in inpatient experiences in the Veterans Affairs (VA) Healthcare System., Objectives: This study aimed to compare inpatient experiences by sex and race/ethnicity within and between VA hospitals., Research Design: We used mixed-effects multinomial regression to assess within-facility and between-facility sex and racial/ethnic differences in the 2010 VA Survey of Healthcare Experiences of Patients., Subjects: 50,471 respondents from 144 VA hospitals (4.5% female; 75.4% non-Hispanic white, 14.7% non-Hispanic black, 5.4% Hispanic, and 4.4% other race/ethnicity)., Measures: Negative and positive patient-reported experiences in 13 health care domains were included., Results: Adjusted within-facility sex differences indicated that women reported more negative and less positive experiences than men in 4 domains, and less negative and more positive experiences on domains related to noise and privacy. Patients at facilities with more female patients reported more negative and less positive experiences in 4 domains. Blacks and Hispanics reported less negative and/or more positive experiences than whites within the same facility, although patients at facilities with more black and Hispanic patients reported more negative and less positive experiences overall. There were few and inconsistent within-facility differences between other racial/ethnic patients and whites. Patients at facilities with more other racial/ethnic patients reported slightly less negative and more positive experiences., Conclusions: Male, black, and Hispanic patients treated in VA hospitals tend to report more positive experiences than female and white patients treated at the same facilities. However, less positive experiences are reported by patients overall in hospitals that serve larger populations of women and racial/ethnic minorities.

Background: Racial and ethnic differences in patient health care experiences have not been well examined in the Veterans Affairs (VA) Healthcare System., Objectives: To examine racial/ethnic differences in outpatient health care experiences within and between VA medical facilities., Research Design: We assessed within-facility and between-facility racial/ethnic differences in responses to the 2010 VA Survey of Healthcare Experiences of Patients using mixed-effects multinomial regression., Subjects: A total of 211,459 respondents (53.2%) to a random survey of outpatients from 910 VA medical facilities (71.9% non-Hispanic white, 15.1% non-Hispanic black, 6.4% Hispanic, and 6.7% Other race/ethnicity)., Measures: Negative and positive patient-reported experiences in 8 domains of health care., Results: Between-facility effects for black race were higher for 7 domains of negative experiences [risk differences (RDs): 0.37% to 1.64%] and lower for 6 domains of positive experiences (RDs: -0.69% to -2.54%). Between-facility effects for Hispanic ethnicity were higher for 5 domains of negative experiences (RDs: 0.60%-1.34%) and lower for 5 domains of positive experiences (RDs: -1.00% to -1.88%). Hispanic ethnicity was also associated with higher within-facility rates of positive experiences for 5 domains of care (RDs: 2.97%-4.08%). Other race/ethnicity was associated with significantly higher within-facility rates of negative experiences (RDs: 2.04%-3.95%) and lower rates of positive experiences for all 8 domains (RDs: -2.05% to -4.70%)., Conclusions: In a national random sample of Veterans managed in the VA Healthcare System, we demonstrated significant within-facility and between-facility racial and ethnic differences in outpatient health care experiences, with differing patterns for each minority group.

Background: Chronic stressors such as perceived discrimination might underlie race disparities in cardiovascular disease. This study focused on the relationship between perceived discrimination and risk of severe coronary obstruction while also accounting for multiple psychosocial variables and clinical factors., Methods: Data from 793 (629 white and 164 black) male veterans with positive nuclear imaging studies were analyzed. Participants were categorized as being at low/moderate or high risk for severe coronary obstruction based on results of their nuclear imaging studies. Hierarchical logistic regression models were tested separately for blacks and whites. The first step of the models included clinical factors. The second step included the psychosocial variables of optimism, religiosity, negative affect, and social support. The final step included perceived discrimination., Results: Perceived discrimination was positively related to risk of severe obstruction among blacks but not among whites after controlling for clinical and psychosocial variables. Similar results were found in patients who underwent coronary angiography (n = 311)., Conclusions: Perceived discrimination was associated with risk of severe coronary obstruction among black male veterans and could be an important target for future interventions., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Background: Many details of the negative relationship between perceived racial/ethnic discrimination and health are poorly understood., Purpose: The purpose of this study was to examine racial/ethnic differences in the relationship between perceived discrimination and self-reported health, identify dimensions of discrimination that drive this relationship, and explore psychological mediators., Methods: Asian, Black, and Latino(a) adults (N=734) completed measures of perceived racial/ethnic discrimination, self-reported health, depression, anxiety, and cynical hostility., Results: The association between perceived discrimination and poor self-reported health was significant and did not differ across racial/ethnic subgroups. Race-related social exclusion and threat/harassment uniquely contributed to poor health for all groups. Depression, anxiety, and cynical hostility fully mediated the effect of social exclusion on health, but did not fully explain the effect of threat., Conclusions: Our results suggest that noxious effects of race-related exclusion and threat transcend between-group differences in discriminatory experiences. The effects of race-related exclusion and threat on health, however, may operate through different mechanisms.

Background: The impact of patients' perceptions of discrimination in healthcare on patient-provider interactions is unknown., Objective: To examine association of past perceived discrimination with subsequent patient-provider communication., Research Design: Observational cross-sectional study., Subjects: African-American (N=100) and white (N=253) patients treated for osteoarthritis by orthopedic surgeons (N=63) in 2 Veterans Affairs facilities., Measures: Patients were surveyed about past experiences with racism and classism in healthcare settings before a clinic visit. Visits were audio-recorded and coded for instrumental and affective communication content (biomedical exchange, psychosocial exchange, rapport-building, and patient engagement/activation) and nonverbal affective tone. After the encounter, patients rated visit informativeness, provider warmth/respectfulness, and ease of communicating with the provider. Regression models stratified by patient race assessed the associations of racism and classism with communication outcomes., Results: Perceived racism and classism were reported by more African-American patients than by white patients (racism: 70% vs. 26% and classism: 73% vs. 53%). High levels of perceived racism among African-American patients was associated with less positive nonverbal affect among patients [β=-0.41, 95% confidence interval (CI)=-0.73 to -0.09] and providers (β=-0.34, 95% CI=-0.66 to -0.01) and with low patient ratings of provider warmth/respectfulness [odds ratio (OR)=0.19, 95% CI=0.05-0.72] and ease of communication (OR=0.22, 95% CI=0.07-0.67). Any perceived racism among white patients was associated with less psychosocial communication (β=-4.18, 95% CI=-7.68 to -0.68), and with low patient ratings of visit informativeness (OR=0.40, 95% CI=0.23-0.71) and ease of communication (OR=0.43, 95% CI=0.20-0.89). Perceived classism yielded similar results., Conclusions: Perceptions of past racism and classism in healthcare settings may negatively impact the affective tone of subsequent patient-provider communication.

Objective: To understand racial disparities in the use of total joint replacement, we examined whether there were racial differences in patient-provider communication about treatment of chronic knee and hip osteoarthritis in a sample of African American and white patients referred to Veterans Affairs orthopedic clinics., Methods: Audio recorded visits between patients and orthopedic surgeons were coded using the Roter Interaction Analysis System and the Informed Decision-Making model. Racial differences in communication outcomes were assessed using linear regression models adjusted for study design, patient characteristics, and clustering by provider., Results: The sample (n = 402) included 296 white and 106 African American patients. Most patients were men (95%) and ages 50-64 years (68%). Almost half (41%) reported an income <$20,000. African American patients were younger and reported lower incomes than white patients. Visits with African American patients contained less discussion of biomedical topics (β = -9.14; 95% confidence interval [95% CI] -16.73, -1.54) and more rapport-building statements (β = 7.84; 95% CI 1.85, 13.82) than visits with white patients. However, no racial differences were observed with regard to length of visit, overall amount of dialogue, discussion of psychosocial issues, patient activation/engagement statements, physician verbal dominance, display of positive affect by patients or providers, or discussion related to informed decision making., Conclusion: In this sample, communication between orthopedic surgeons and patients regarding the management of chronic knee and hip osteoarthritis did not, for the most part, vary by patient race. These findings diminish the potential role of communication in Veterans Affairs orthopedic settings as an explanation for well-documented racial disparities in the use of total joint replacement., (Copyright © 2011 by the American College of Rheumatology.)

Objectives: Examine whether three measures of perceived racial discrimination in health care detect similar rates of discrimination and show similar associations with patients' healthcare experiences., Design: Cross-sectional observational study involving telephone surveys and medical record reviews., Setting: Veterans Affairs Pittsburgh Healthcare System., Participants: 50 White and 50 African American veterans with diabetes., Main Outcome Measures: Three types of measures of perceived racial discrimination in health care were compared: single-item and multi-item measures assessing personal experiences of discrimination in healthcare settings, and a measure assessing general racism in the healthcare system. Associations of each measure with patient-reported problems with their medical care and receipt of recommended preventive screenings were also explored., Results: More African American than White veterans reported perceived discrimination on all measures (personal discrimination, single-item: 42% vs 6%, P<.001; personal discrimination, multi-item: 42% vs 18%, P=.01; general racism: 74% vs 40%, P=.001). In the total sample, discrimination was more likely to be reported on the general racism measure than on the single-item (OR=36.53, 95% CI=7.95-167.89) or multi-item measures (OR=20.28, 95% CI=5.12-80.34) of personal discrimination. The multi-item measure of personal discrimination (OR=3.96, 95% CI=1.29-12.18) and general racism measure (OR=3.61, 95% CI=1.34-9.71) were significantly associated with patient-reported problems with their care. Receipt of recommended screenings was not associated with any of the discrimination measures., Conclusions: Different measures of perceived racial discrimination in healthcare settings yield different rates of discrimination and show variable associations with patients' perceptions of care.

Background: We examined whether diabetes-related psychosocial factors differ between African American and white patients with type 2 diabetes. We also tested whether racial differences in glycemic control are independent of such factors., Methods: Baseline glycosylated hemoglobin (HbA(1c)) and survey measures from 79 African American and 203 white adult participants in a diabetes self-management clinical trial were analyzed., Results: Several psychosocial characteristics varied by race. Perceived interference of diabetes with daily life, perceived diabetes severity, and diabetes-related emotional distress were higher for African Americans than for whites, as were access to illness-management resources and social support. Mean HbA(1c) levels were higher among African Americans than whites (8.14 vs 7.40, beta = 0.17). This difference persisted after adjusting for demographic, clinical, and diabetes-related psychosocial characteristics that differed by race (beta = 0.18). Less access to illness-management resources (beta = -0.25) and greater perceived severity of diabetes (beta = 0.21) also predicted higher HbA(1c)., Discussion: Although racial differences in diabetes-related psychosocial factors were observed, African Americans continued to have poorer glycemic control than whites even after such differences were taken into account. Interventions that target psychosocial factors related to diabetes management, particularly illness-management resources, may be a promising way to improve glycemic control for all patients.

Background: The extent to which treatment recommendations in the orthopedic setting contribute to well-established racial disparities in the utilization of total joint replacement (TJR) in the treatment of advanced knee/hip osteoarthritis has not been explored., Objective: To examine whether orthopedic surgeons are less likely to recommend TJR to African-American patients compared to white patients with similar clinical indications, and whether there are racial differences in the receipt of TJR within six months of study enrollment., Design: Prospective, observational study., Participants: African-American (AA; n = 120) and white (n = 337) patients seeking treatment for knee or hip osteoarthritis in Veterans Affairs orthopedic clinics., Main Measures: Patients completed surveys that assessed socio-demographic and clinical variables that could influence osteoarthritis treatment. Orthopedic surgeons' notes were reviewed to determine whether patients had been recommended for TJR and whether they underwent the procedure within 6 months of study enrollment., Results: Rate of TJR recommendation was 19.5%. Odds of receiving a TJR recommendation were lower for AA than white patients of similar age and disease severity (OR = 0.46, 95% CI = 0.26-0.83; P = 0.01). However, this difference was not significant after adjusting for patient preference for TJR (OR = 0.69, 95% CI = 0.36-1.31, P = 0.25). Overall, 10.3% of patients underwent TJR within 6 months. TJR was less likely for AA patients than for white patients of similar age and disease severity (OR = 0.41, 95% CI = 0.16-1.05, P = 0.06), but this difference was reduced after adjusting for whether patients had received a recommendation for the procedure at the index visit (OR = 0.57, 95% CI = 0.21-1.54, P = 0.27)., Conclusions: In this study, race differences in patient preferences for TJR appeared to underlie race differences in TJR recommendations, which led to race differences in utilization of the procedure. Our findings suggest that patient treatment preferences play an important role in racial disparities in TJR utilization in the orthopedic setting.

Objectives: We compared rates of perceived racial discrimination in health care settings for veteran and nonveteran patients and for veterans who used the Veterans Affairs health care system and those who did not., Methods: Data were drawn from the 2004 Behavioral Risk Factor Surveillance System. We used logistic regression to examine whether perceived racial discrimination in health care was associated with veteran status or use of Veterans Affairs health care, after adjusting for patient characteristics., Results: In this sample of 35,902 people, rates of perceived discrimination were equal for veterans and nonveterans (3.4% and 3.5%, respectively; crude odds ratio [OR] = 1.00; 95% confidence interval [CI] = 0.77, 1.28; adjusted OR = 0.92; 95% CI = 0.66, 1.28). Among veterans (n = 3420), perceived discrimination was more prevalent among patients who used Veterans Affairs facilities than among those who did not (5.4% vs 2.7%; OR = 2.08; 95% CI = 1.04, 4.18). However, this difference was not significant after adjustment for patient characteristics (OR = 1.30; 95% CI = 0.54, 3.13)., Conclusions: Perceived racial discrimination in health care was equally prevalent among veterans and nonveterans and among veterans who used the Veterans Affairs health care system and those who did not.

Background: The extent to which racial/ethnic disparities in pneumonia care occur within or between hospitals is unclear., Objective: Examine within and between-hospital racial/ethnic disparities in quality indicators and mortality for patients hospitalized for pneumonia., Research Design: Retrospective cohort study., Subjects: A total of 1,183,753 non-Hispanic white, African American, and Hispanic adults hospitalized for pneumonia between January 2005 and June 2006., Measures: Eight pneumonia care quality indicators and in-hospital mortality., Results: Performance rates for the 8 quality indicators ranged from 99.4% (oxygenation assessment within 24 hours) to 60.2% (influenza vaccination). Overall hospital mortality was 4.1%. African American and Hispanic patients were less likely to receive pneumococcal and influenza vaccinations, smoking cessation counseling, and first dose of antibiotic within 4 hours than white patients at the same hospital (ORs = 0.65-0.95). Patients at hospitals with the racial composition of those attended by average African Americans and Hispanics were less likely to receive all indicators except blood culture within 24 hours than patients at hospitals with the racial composition of those attended by average whites. Hospital mortality was higher for African Americans (OR = 1.05; 95% CI = 1.02, 1.09) and lower for Hispanics (OR = 0.85; 95% CI = 0.81, 0.89) than for whites within the same hospital. Mortality for patients at hospitals with the racial composition of those attended by average African Americans (OR = 1.21; 95% CI = 1.18, 1.25) or Hispanics (OR = 1.18; 95% CI = 1.14, 1.23) was higher than for patients at hospitals with the racial composition of those attended by average whites., Conclusions: Racial/ethnic disparities in pneumonia treatment and mortality are larger and more consistent between hospitals than within hospitals.

Objectives: We sought to identify factors associated with appointment nonattendance for diagnostic testing of coronary artery disease among veterans. For patients with possible heart disease, appointment nonattendance may seriously compromise short- and long-term outcomes. Understanding factors associated with nonattendance may help improve care while reducing inefficiency in service delivery., Methods: We surveyed patients who attended (n = 240) or did not attend (n = 139) a scheduled cardiac appointment at a midwestern Veterans Administration medical center. Multivariable regression models were used to assess factors associated with nonattendance., Results: Younger age, lower income, unemployment, and longer wait times for appointments were predictive of nonattendance. Nonattenders reported fewer cardiac symptoms and were more likely to attribute their symptoms to something other than heart disease. Nonattendance was also associated with a coping style characterized by avoidance of aversive information. Logistical issues, fear of diagnostic procedures, disbelief that one had heart disease, and medical mistrust were some of the reasons given for missed appointments., Conclusions: Appointment nonattendance among veterans scheduled for cardiology evaluation was associated with several important cognitive factors. These factors should be considered when one is designing clinical systems to reduce patient nonattendance.

Objective: To examine the relationship between perceived discrimination and preventive health care utilization., Design and Participants: Cross-sectional analysis using the 2004 Behavioral Risk Factor Surveillance System "Reactions to Race" module (N = 28,839)., Measurements: Outcomes were self-reported utilization of seven preventive health services. Predictors included perceived negative and positive racial discrimination (vs. none) while seeking health care in the past year. Multivariable models adjusted for additional patient characteristics., Main Results: In unadjusted models, negative discrimination was significantly associated with less utilization of mammogram, pap test, PSA test, blood stool test, and sigmoidoscopy/colonoscopy (ORs = 0.53-0.73, p < .05), but not flu or pneumococcal vaccines (ORs = 0.76 and 0.84). Positive discrimination was significantly associated with more utilization of all services (ORs = 1.29-1.58, p < .05) except pap test (OR = 0.94). In adjusted models, neither negative nor positive discrimination was predictive of utilization, except for PSA test (positive discrimination OR = 1.33, p < .05)., Conclusions: Perceived racial discrimination in health care does not independently predict preventive health care utilization.

Background: Despite the surge of recent research on the association between perceived discrimination and health-related outcomes, few studies have focused on race-based discrimination encountered in health care settings. This study examined the prevalence of such discrimination, and its association with health status, for the 3 largest race/ethnic groups in the United States., Methods: Data were drawn from the 2004 Behavioral Risk Factor Surveillance System survey. The primary variables were perceived racial discrimination in health care and self-reported health status. Multivariable logistic regression was used to compare the prevalence of perceived discrimination for whites, African Americans, and Hispanics, and to examine the association between perceived discrimination and health status, controlling for sex, age, income, education, health care coverage, affordability of medical care, racial salience, and state., Results: Perceived discrimination was reported by 2%, 5.2%, and 10.9% of whites, Hispanics, and African Americans, respectively. Only the difference between African Americans and whites remained significant in adjusted analyses [odds ratio (OR) = 3.22, 95% confidence interval (CI) = 2.46-4.21]. Racial/ethnic differences in perceived discrimination depended on income, education, health care coverage, and affordability of medical care. Perceived discrimination was associated with worse health status for the overall sample (OR = 1.71, 95% CI = 1.35-2.16). Stratified analyses revealed that this relationship was significant for whites (OR = 2.00, 95% CI = 1.45-2.77) and African Americans (OR = 1.95, 95% CI = 1.39-2.73), but not for Hispanics (OR = 0.55, 95% CI = 0.24-1.22)., Conclusions: Perceived racial discrimination in health care is much more prevalent for African Americans than for whites or Hispanics. Furthermore, such discrimination is associated with worse health both for African Americans and for whites.

Research on the effects of school desegregation, once quite common in psychology and related fields, has declined considerably since the mid-1980s. Factors contributing to changes in the quantity and focus of such research since the Brown v. Board of Education (1954) decision are discussed, with an emphasis on those related to the decline of this research in the last 2 decades. These factors include the nation's retreat from the policy of school desegregation and the associated decline in research funding. Changing perspectives regarding desegregation, the outcomes of desegregation that merit study, and the desirable composition of research teams studying desegregation have also played a role. Demographic changes in our society and its schools that have made salient other research topics and the development of effective research paradigms for studying intergroup relations in the laboratory have also contributed to this decline. ((c) 2004 APA, all rights reserved)

The authors examine stigmatization and mental illness, focusing on the role of perceived group variability in stereotype use. Consumers' and providers' in-group and out-group stereotypes were assessed. Although providers had extensive experience, they judged consumers more stereotypically and just as negatively as did the consumers themselves. Consumers' education and involvement in services were weakly predictive of more stereotypic, less variable, and more negative views of providers, whereas providers' education and involvement in services predicted more stereotypic but also more variable views of both groups. Perceived group stereotypicality predicted more stereotypic judgments of individuals, whereas perceived variability predicted less confidence in judgments. Because providers perceived greater variability, they were less confident in applying the stereotype to individuals. We suggest that increasing perceptions of the variability among consumers may lead to more sensitive use of diagnostic criteria, more individualized treatment, and a decrease in the negative effects of stigmatization.