Evans, Michael D.

BACKGROUND AND OBJECTIVES Some Minnesota clinicians perceive that the incidence of prophylactic vitamin K refusal is increasing, yet the actual incidence and which populations are most likely to refuse is unknown. Our objective is to identify the incidence of vitamin K refusal and to characterize the maternal-newborn dyads with increased refusal rates. METHODS This retrospective multi-institution study analyzed vitamin K refusal in newborns born from 2015 to 2019. Maternal-newborn dyad delivery and community characteristics (language, religion, population size) were collected and analyzed by univariable and multivariable logistic regression. RESULTS Among 102 451 term infants, 1.3% did not receive intramuscular vitamin K. Refusal increased from 0.9% in 2015 to 1.6% by 2019 (P < .0001). In multivariable analysis, factors associated with increased likelihood of refusal included female sex (odds ratio [OR] 1.22, 95% CI 1.09–1.36), exclusive human milk feeding at hospital discharge (OR 3.46, 95% CI 2.87–4.17), parity greater than 0 (OR ranging from 1.32 [95% CI 1.13–1.54] for parity of 1, to 3.70 [95% CI 2.80–4.90] for parity of 4), having a midwife at delivery (OR 1.70, 95% CI 1.45–2.01), public insurance (OR 1.84, 95% CI 1.60–2.12), and Russian language (OR 4.92, 95% CI 2.90–8.35). Some religious identities had higher refusal rates (ie, Pentecostal 7.0%, Baptist 3.3%). CONCLUSION In a cohort of Minnesota hospital-born infants, the incidence of vitamin K refusal increased between 2015 and 2019. We identified large populations (eg, public insurance, exclusive human milk feeding) and smaller discrete communities (eg, Russian, Pentecostal) with opportunities for increasing prophylactic vitamin K acceptance through targeted community conversations.

Abstract Immune thrombotic thrombocytopenic purpura (iTTP) is a chronically relapsing disorder caused by autoantibody-mediated deficiency of ADAMTS13. Rituximab is frequently administered to prevent relapses, but whether the durability of rituximab effect is maintained with subsequent treatment courses has not been studied. Using the United States Thrombotic Microangiopathy Consortium (USTMA) retrospective iTTP registry, we evaluated clinical relapse-free survival (RFS) with subsequent courses of rituximab treatment in multiply relapsing patients. Separately, we evaluated overall RFS (composite of time to clinical relapse, ADAMTS13 relapse, or preemptive rituximab) in a prospective iTTP cohort from the Johns Hopkins University and the University of Minnesota. In the USTMA registry, median clinical RFS was shorter after the second or subsequent rituximab-treated episode than the first (2.1 vs 6.0 years; P = .04). White patients’ clinical relapse risk after the second and subsequent rituximab courses was not significantly different compared with the first (hazard ratio [HR], 1.86; 95% confidence interval [CI], 0.22-15.80; P = .57), whereas for Black patients, clinical relapse risk was significantly higher after the second or subsequent courses (HR, 2.82; 95% CI, 1.52-5.24; P = .001). In the prospective cohort, overall RFS progressively shortened after each episode of rituximab treatment with the first episode having the longest RFS (2.8 years; interquartile range, 2.0-6.0) and this loss of response durability was most pronounced in Black patients. The durability of rituximab’s effect declines with subsequent treatments, which is more pronounced in Black patients, who may benefit from closer monitoring and alternative immunomodulatory approaches such as maintenance rituximab and consideration of other agents.

Healthcare inequities are often attributed to large-scale structural barriers for access to medical care or patient-medical staff interactions. However, the role of the electronic medical record (EMR) in perpetuating hidden biases has been poorly characterized. This passive form of sharing implicit biases with unknown readers may have profound ripple effects asynchronous in place and time from the note writer. This study aims to illustrate racial imbalances in ad hominem patient characterizations as documented by medical staff, regardless of role, in a large metro healthcare system. The use of certain potentially stigmatizing language in emergency department (ED) and inpatient notes for hematology/oncology patients was investigated. Retrospective chart review of four hospitals within a university network in a major metro area between 1/1/2019 - 6/30/2021 was undertaken. Patients ≥22 years old were included with two primary hypotheses in mind: 1) Negative terms are used more frequently for underrepresented minorities, and 2) words with shock value (i.e. curse words) are used more often than more general descriptors of these terms (e.g. “cursing” or “profanity”). Nine positive and twelve negative terms were evaluated, based on the authors' observations of their use in the EMR in past encounters (Table 1). Some were personal descriptors in which the ED or inpatient note writer would be less likely than outpatient providers to have a full sense of outpatient care or social determinants of health (e.g. compliant). Others were behavioral descriptions (e.g. hostile) or words with minimal medical relevance (e.g. curse words). If multiple notes in an encounter included the same word(s), the encounter was only analyzed once for each word to avoid word count inflation, though re-occurrences for the same patient in subsequent encounters were counted. Authors' manual data review using natural language processing software confirmed appropriate use of terms. Generalized estimating equations were used for race-based comparisons to account for same-patient clustered encounters. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for self-reported demographic comparisons with White as the reference category. P≤0.05 was considered significant. A total of 1,059 encounters for 889 hematology/oncology patients were analyzed. Mean age was 61 years (standard deviation 16.7) and 49.4% were female. White race was reported for 80.2% of patients (72% system-wide prevalence during same timeframe) and Black for 11.4% (15.2% system-wide); all others were ≤4% so only White/Black comparisons were included. Positive terms were more prevalent than negative ones (n=535 vs 459). However, negative terms were found more often for Black individuals (OR 2.24, CI 1.41 - 3.56, P<0.001), while the positive terms were less frequently documented in Black patients relative to White patients (OR 0.51, CI 0.33 - 0.77, P=0.001), and neither category was concordant with the overall patient racial demographics. Other significant racial differences existed for the terms “Argumentative”, “Disrespectful”, “Noncompliant”, and “Polite”, all discrepancies which favored White patients (Table 2). Specific curse words were documented nearly as often as “cursing”, “swearing”, or “profanity”, but no racial differences were observed. Some words in the initial search (“Brave”, “Courageous”, “Empathetic”, and “Ambitious”) were not found in hematology/oncology notes in this timeframe. EMR documentation in hospital-based hematology/oncology care demonstrated evidence of racial discrepancies in language that may carry stigma, positively or negatively. Importantly, many of these terms have questionable, if any, medical relevance. The use of stigmatizing terminology in the EMR may reflect implicit biases that extend past the direct patient encounter, passively and subconsciously prejudicing future care from other staff members. Time-saving heuristics and documentation shortcuts like copy-forwarding may further ossify healthcare inequities. This phenomenon is undoubtedly not limited to this hospital system or the hematology/oncology field, but quantitative real-world evidence has been scant. Improved awareness of stigmatizing language in documentation may be one step towards mitigating this contributor to unequal care for hematology/oncology providers and their patients.

Abstract Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is characterized by recurring episodes of thrombotic microangiopathy, causing ischemic organ impairment. Black patients are overrepresented in iTTP cohorts in the United States, but racial disparities in iTTP outcome and response to therapy have not been studied. Using the United States Thrombotic Microangiopathies Consortium iTTP Registry, we evaluated the impact of race on mortality and relapse-free survival (RFS) in confirmed iTTP in the United States from 1995 to 2020. We separately examined the impact of rituximab therapy and presentation with newly diagnosed (de novo) or relapsed iTTP on RFS by race. A total of 645 participants with 1308 iTTP episodes were available for analysis. Acute iTTP mortality did not differ by race. When all episodes of iTTP were included, Black race was associated with shorter RFS (hazard ratio [HR], 1.60; 95% CI, 1.16-2.21); the addition of rituximab to corticosteroids improved RFS in White (HR, 0.37; 95% CI, 0.18-0.73) but not Black patients (HR, 0.96; 95% CI, 0.71-1.31). In de novo iTTP, rituximab delayed relapse, but Black patients had shorter RFS than White patients, regardless of treatment. In relapsed iTTP, rituximab significantly improved RFS in White but not Black patients. Race affects overall relapse risk and response to rituximab in iTTP. Black patients may require closer monitoring, earlier retreatment, and alternative immunosuppression after rituximab treatment. How race, racism, and social determinants of health contribute to the disparity in relapse risk in iTTP deserves further study.