title: An investigation of associations between clinicians' ethnic or racial bias and hypertension treatment, medication adherence and blood pressure control.
abstract: BACKGROUND
  Few studies have directly investigated the association of clinicians' implicit (unconscious) bias with health care disparities in clinical settings.
  
  
  OBJECTIVE
  To determine if clinicians' implicit ethnic or racial bias is associated with processes and outcomes of treatment for hypertension among black and Latino patients, relative to white patients.
  
  
  METHODS
  Primary care clinicians completed Implicit Association Tests of ethnic and racial bias. Electronic medical records were queried for a stratified, random sample of the clinicians' black, Latino and white patients to assess treatment intensification, adherence and control of hypertension. Multilevel random coefficient models assessed the associations between clinicians' implicit biases and ethnic or racial differences in hypertension care and outcomes.
  
  
  METHODS
  Standard measures of treatment intensification and medication adherence were calculated from pharmacy refills. Hypertension control was assessed by the percentage of time that patients met blood pressure goals recorded during primary care visits.
  
  
  RESULTS
  One hundred and thirty-eight primary care clinicians and 4,794 patients with hypertension participated. Black patients received equivalent treatment intensification, but had lower medication adherence and worse hypertension control than white patients; Latino patients received equivalent treatment intensification and had similar hypertension control, but lower medication adherence than white patients. Differences in treatment intensification, medication adherence and hypertension control were unrelated to clinician implicit bias for black patients (P = 0.85, P = 0.06 and P = 0.31, respectively) and for Latino patients (P = 0.55, P = 0.40 and P = 0.79, respectively). An increase in clinician bias from average to strong was associated with a relative change of less than 5 % in all outcomes for black and Latino patients.
  
  
  CONCLUSIONS
  Implicit bias did not affect clinicians' provision of care to their minority patients, nor did it affect the patients' outcomes. The identification of health care contexts in which bias does not impact outcomes can assist both patients and clinicians in their efforts to build trust and partnership.
authors.affiliation: Department of Psychology & Neuroscience, University of Colorado, UCB 345, Boulder, CO, 80309, USA, irene.blair@colorado.edu.
authors.forename: Irene V
authors.initials: IV
authors.lastname: Blair
authors.forename: John F
authors.initials: JF
authors.lastname: Steiner
authors.forename: Rebecca
authors.initials: R
authors.lastname: Hanratty
authors.forename: David W
authors.initials: DW
authors.lastname: Price
authors.forename: Diane L
authors.initials: DL
authors.lastname: Fairclough
authors.forename: Stacie L
authors.initials: SL
authors.lastname: Daugherty
authors.forename: Michael
authors.initials: M
authors.lastname: Bronsert
authors.forename: David J
authors.initials: DJ
authors.lastname: Magid
authors.forename: Edward P
authors.initials: EP
authors.lastname: Havranek
mesh_terms: D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001794:Blood Pressure; D001795:Blood Pressure Determination / Q000379:methods*; D003120:Colorado / Q000453:epidemiology; D005006:Ethnicity; D005260:Female; D005500:Follow-Up Studies; D054625:Healthcare Disparities; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000208:ethnology / Q000503:physiopathology; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D010865:Pilot Projects; D015995:Prevalence; D011320:Primary Health Care / Q000379:methods*; D012189:Retrospective Studies
chemical_list: D000959:Antihypertensive Agents