{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T03:32:22Z","timestamp":1787628742157,"version":"build-2736575974"},"reference-count":35,"publisher":"American Medical Association (AMA)","issue":"5","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Surg"],"published-print":{"date-parts":[[2025,5,1]]},"abstract":"Importance<\/jats:title>Implicit bias may influence physician treatment decisions and contribute to Black-White health disparities. There are limited data linking implicit bias with actual care delivery and outcomes.<\/jats:p><\/jats:sec>Objective<\/jats:title>To determine whether implicit racial bias is associated with potentially harmful surgical treatment selection for a cohort of patients with peripheral artery disease\u2013related claudication.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>This survey study, linked with observational registry data, included eligible clinicians who participate in the Vascular Quality Initiative (VQI) among 960 centers. The VQI includes academic medical centers, teaching hospitals, community hospitals, and private practices. Eligible participants included all vascular specialist VQI members (N\u2009=\u20092512), of whom 218 completed the race implicit association test (IAT) and were linkable to procedure-level data. The study was conducted between October 2021 and October 2022.<\/jats:p><\/jats:sec>Exposure<\/jats:title>Race IAT.<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>Clinician-level implicit bias results were linked to patient-level registry data of peripheral revascularization procedures performed for claudication. The adjusted odds of performance of any infrapopliteal procedure by specialist implicit bias and patient race were measured via mixed-effects logistic regression models. Implicit bias as a moderator of the association of infrapopliteal procedures for claudication and patient race with 1-year amputation was assessed as a secondary outcome.<\/jats:p><\/jats:sec>Results<\/jats:title>Among 218 vascular specialists (mean [SD] age, 46 [9] years; 160 [73%] male), 157 (72%) had a pro-White bias. Black patients treated by a physician with pro-White bias had a significant increase in the odds of receiving an infrapopliteal procedure compared with the total sample (adjusted odds ratio [AOR], 1.67; 95% CI, 1.12-2.48). When treated by a specialist with pro-White bias, Black patients had increased odds of 1-year amputation, regardless of anatomic location treated, compared with White patients (AOR, 2.34; 95% CI, 1.20-4.55). Conversely, Black patients treated by a specialist with no bias had similar odds of an infrapopliteal procedure (AOR, 0.93; 95% CI, 0.68-1.26) as the full patient sample and similar odds of 1-year amputation (AOR, 1.29; 95% CI, 0.33-4.99) as White patients.<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>These findings indicate that implicit bias is associated with potentially harmful infrapopliteal procedures for Black patients and contributes to Black-White outcome disparities in the US. 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 influence of implicit bias.<\/jats:p><\/jats:sec>","DOI":"10.1001\/jamasurg.2024.7254","type":"journal-article","created":{"date-parts":[[2025,2,26]],"date-time":"2025-02-26T16:32:55Z","timestamp":1740587575000},"page":"536","source":"Crossref","is-referenced-by-count":20,"title":["Implicit Racial Bias and Unintentional Harm in Vascular Care"],"prefix":"10.1001","volume":"160","author":[{"given":"Corey A.","family":"Kalbaugh","sequence":"first","affiliation":[{"name":"Department of Epidemiology and Biostatistics, Indiana University School of Public Health\u2013Bloomington, Bloomington"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erika T.","family":"Beidelman","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, Indiana University School of Public Health\u2013Bloomington, Bloomington"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kerry A.","family":"Howard","sequence":"additional","affiliation":[{"name":"Department of Public Health Sciences, Clemson University, Clemson, South Carolina"},{"name":"Center for Public Health Modeling and Response, Clemson University, Clemson, South Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brian","family":"Witrick","sequence":"additional","affiliation":[{"name":"Department of Public Health Sciences, Clemson University, Clemson, South Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashley","family":"Clark","sequence":"additional","affiliation":[{"name":"Center for Survey Research and O\u2019Neill School of Public and Environmental Affairs, Indiana University\u2013Bloomington, Bloomington"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katharine L.","family":"McGinigle","sequence":"additional","affiliation":[{"name":"Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samantha","family":"Minc","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular and Thoracic Surgery, West Virginia School of Medicine, Morgantown"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Olamide","family":"Alabi","sequence":"additional","affiliation":[{"name":"Department of Surgery, Emory University School of Medicine, Atlanta, Georgia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caitlin W.","family":"Hicks","sequence":"additional","affiliation":[{"name":"Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew A.","family":"Gonzalez","sequence":"additional","affiliation":[{"name":"Department of Surgery, Indiana University School of Medicine; Indianapolis"},{"name":"Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Crystal W.","family":"Cen\u00e9","sequence":"additional","affiliation":[{"name":"Department of Medicine, University of California at San Diego Health, La Jolla"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samuel","family":"Cykert","sequence":"additional","affiliation":[{"name":"Division of General Medicine and Clinical Epidemiology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","reference":[{"issue":"9","key":"soi240113r1","doi-asserted-by":"publisher","first-page":"e171","DOI":"10.1161\/CIR.0000000000001005","article-title":"Lower extremity peripheral artery disease: contemporary epidemiology, management gaps, and future directions: a scientific statement from the American Heart Association.","volume":"144","author":"Criqui","year":"2021","journal-title":"Circulation"},{"key":"soi240113r2","doi-asserted-by":"publisher","first-page":"292","DOI":"10.1016\/j.avsg.2015.07.040","article-title":"Amputation rates for patients with diabetes and peripheral arterial disease: the effects of race and region.","volume":"30","author":"Newhall","year":"2016","journal-title":"Ann Vasc Surg"},{"issue":"1","key":"soi240113r3","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1177\/1358863X231196139","article-title":"Investigating the impact of suboptimal prescription of preoperative antiplatelets and statins on race and ethnicity-related disparities in major limb amputation.","volume":"29","author":"Kalbaugh","year":"2024","journal-title":"Vasc Med"},{"issue":"2","key":"soi240113r4","doi-asserted-by":"publisher","first-page":"611","DOI":"10.1016\/j.jvs.2019.10.075","article-title":"Race and socioeconomic differences associated with endovascular peripheral vascular interventions for newly diagnosed claudication.","volume":"72","author":"Hicks","year":"2020","journal-title":"J Vasc Surg"},{"key":"soi240113r5","doi-asserted-by":"publisher","first-page":"AP105","DOI":"10.1161\/circ.145.suppl_1.P105","article-title":"Abstract P105: bypasses to below-knee arteries may expedite amputation in patients with claudication.","volume":"145","author":"Kalbaugh","year":"2022","journal-title":"Circulation"},{"issue":"3","key":"soi240113r6","doi-asserted-by":"publisher","first-page":"2S","DOI":"10.1016\/j.jvs.2014.12.009","article-title":"Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication.","volume":"61","author":"Conte","year":"2015","journal-title":"J Vasc Surg"},{"issue":"1","key":"soi240113r7","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1016\/j.jvs.2022.04.012","article-title":"Society for Vascular Surgery appropriate use criteria for management of intermittent claudication.","volume":"76","author":"Woo","year":"2022","journal-title":"J Vasc Surg"},{"issue":"1","key":"soi240113r8","doi-asserted-by":"publisher","first-page":"89","DOI":"10.1016\/j.ejvs.2024.06.017","article-title":"Infrapopliteal peripheral vascular interventions for claudication are performed frequently in the USA and are associated with poor long term outcomes.","volume":"69","author":"Bose","year":"2025","journal-title":"Eur J Vasc Endovasc Surg"},{"issue":"1","key":"soi240113r9","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1037\/0033-295X.102.1.4","article-title":"Implicit social cognition: attitudes, self-esteem, and stereotypes.","volume":"102","author":"Greenwald","year":"1995","journal-title":"Psychol Rev"},{"key":"soi240113r10","doi-asserted-by":"publisher","first-page":"219","DOI":"10.1016\/j.socscimed.2017.05.009","article-title":"A decade of studying implicit racial\/ethnic bias in healthcare providers using the implicit association test.","volume":"199","author":"Maina","year":"2018","journal-title":"Soc Sci Med"},{"issue":"1","key":"soi240113r11","doi-asserted-by":"publisher","first-page":"19","DOI":"10.1186\/s12910-017-0179-8","article-title":"Implicit bias in healthcare professionals: a systematic review.","volume":"18","author":"FitzGerald","year":"2017","journal-title":"BMC Med Ethics"},{"issue":"8","key":"soi240113r12","doi-asserted-by":"publisher","first-page":"895","DOI":"10.1111\/acem.13214","article-title":"A systematic review of the impact of physician implicit racial bias on clinical decision making.","volume":"24","author":"Dehon","year":"2017","journal-title":"Acad Emerg Med"},{"issue":"6","key":"soi240113r13","doi-asserted-by":"publisher","first-page":"813","DOI":"10.1016\/S0277-9536(99)00338-X","article-title":"The effect of patient race and socio-economic status on physicians\u2019 perceptions of patients.","volume":"50","author":"van Ryn","year":"2000","journal-title":"Soc Sci Med"},{"issue":"8","key":"soi240113r14","doi-asserted-by":"publisher","first-page":"618","DOI":"10.1056\/NEJM199902253400806","article-title":"The effect of race and sex on physicians\u2019 recommendations for cardiac catheterization.","volume":"340","author":"Schulman","year":"1999","journal-title":"N Engl J Med"},{"issue":"6","key":"soi240113r15","doi-asserted-by":"publisher","first-page":"1464","DOI":"10.1037\/0022-3514.74.6.1464","article-title":"Measuring individual differences in implicit cognition: the implicit association test.","volume":"74","author":"Greenwald","year":"1998","journal-title":"J Pers Soc Psychol"},{"issue":"5","key":"soi240113r16","doi-asserted-by":"publisher","first-page":"1529","DOI":"10.1016\/j.jvs.2012.03.016","article-title":"The Society for Vascular Surgery Vascular Quality Initiative.","volume":"55","author":"Cronenwett","year":"2012","journal-title":"J Vasc Surg"},{"key":"soi240113r17","doi-asserted-by":"publisher","first-page":"1720","DOI":"10.1016\/j.jvs.2023.04.023","article-title":"Reprint of: Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia.","volume":"77","author":"Sorber","year":"2023","journal-title":"J Vasc Surg"},{"issue":"1","key":"soi240113r18","doi-asserted-by":"publisher","first-page":"98","DOI":"10.1001\/jamainternmed.2023.6300","article-title":"Population weighting in statistical analysis.","volume":"184","author":"Si","year":"2024","journal-title":"JAMA Intern Med"},{"issue":"17","key":"soi240113r19","doi-asserted-by":"publisher","first-page":"1805","DOI":"10.1001\/jama.2012.3532","article-title":"Response rates and nonresponse errors in surveys.","volume":"307","author":"Johnson","year":"2012","journal-title":"JAMA"},{"key":"soi240113r20","doi-asserted-by":"publisher","first-page":"123","DOI":"10.1016\/j.socscimed.2013.03.016","article-title":"Racial attitudes, physician-patient talk time ratio, and adherence in racially discordant medical interactions.","volume":"87","author":"Hagiwara","year":"2013","journal-title":"Soc Sci Med"},{"issue":"24","key":"soi240113r21","doi-asserted-by":"publisher","first-page":"2874","DOI":"10.1200\/JCO.2015.66.3658","article-title":"The effects of oncologist implicit racial bias in racially discordant oncology interactions.","volume":"34","author":"Penner","year":"2016","journal-title":"J Clin Oncol"},{"issue":"5","key":"soi240113r22","doi-asserted-by":"publisher","first-page":"457","DOI":"10.1001\/jamasurg.2014.4038","article-title":"Unconscious race and social class bias among acute care surgical clinicians and clinical treatment decisions.","volume":"150","author":"Haider","year":"2015","journal-title":"JAMA Surg"},{"issue":"9","key":"soi240113r23","doi-asserted-by":"publisher","first-page":"1231","DOI":"10.1007\/s11606-007-0258-5","article-title":"Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients.","volume":"22","author":"Green","year":"2007","journal-title":"J Gen Intern Med"},{"issue":"6","key":"soi240113r24","first-page":"795","article-title":"Intermittent claudication: its natural course.","volume":"78","author":"Imparato","year":"1975","journal-title":"Surgery"},{"key":"soi240113r25","doi-asserted-by":"publisher","first-page":"24","DOI":"10.1016\/j.avsg.2023.01.010","article-title":"Variations in practice patterns for peripheral vascular interventions across clinical settings.","volume":"92","author":"Haqqani","year":"2023","journal-title":"Ann Vasc Surg"},{"issue":"5","key":"soi240113r26","doi-asserted-by":"publisher","first-page":"468","DOI":"10.1016\/j.jnma.2019.03.001","article-title":"A multi-faceted intervention aimed at black-white disparities in the treatment of early stage cancers: the ACCURE pragmatic quality improvement trial.","volume":"112","author":"Cykert","year":"2020","journal-title":"J Natl Med Assoc"},{"issue":"3","key":"soi240113r27","doi-asserted-by":"publisher","first-page":"1095","DOI":"10.1002\/cam4.2005","article-title":"A system-based intervention to reduce Black-White disparities in the treatment of early stage lung cancer: a pragmatic trial at five cancer centers.","volume":"8","author":"Cykert","year":"2019","journal-title":"Cancer Med"},{"key":"soi240113r28","doi-asserted-by":"publisher","first-page":"A36","DOI":"10.1161\/circ.149.suppl_1.36","article-title":"Clinical guidelines may help mitigate the impact of physician implicit bias on patient care and treatment.","volume":"149","author":"Beidelman","year":"2024","journal-title":"Circulation"},{"issue":"1","key":"soi240113r30","doi-asserted-by":"publisher","first-page":"7","DOI":"10.1177\/15291006211070781","article-title":"Implicit-bias remedies: treating discriminatory bias as a public-health problem.","volume":"23","author":"Greenwald","year":"2022","journal-title":"Psychol Sci Public Interest"},{"issue":"2","key":"soi240113r31","doi-asserted-by":"publisher","first-page":"171","DOI":"10.1037\/a0032734","article-title":"Predicting ethnic and racial discrimination: a meta-analysis of IAT criterion studies.","volume":"105","author":"Oswald","year":"2013","journal-title":"J Pers Soc Psychol"},{"issue":"1","key":"soi240113r32","doi-asserted-by":"publisher","first-page":"27","DOI":"10.1037\/0003-066X.61.1.27","article-title":"Arbitrary metrics in psychology.","volume":"61","author":"Blanton","year":"2006","journal-title":"Am Psychol"},{"key":"soi240113r33","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1080\/10463280701489053","article-title":"Pervasiveness and correlates of implicit attitudes and stereotypes.","volume":"18","author":"Nosek","year":"2007","journal-title":"Eur Rev Soc Psychol"},{"key":"soi240113r34","doi-asserted-by":"publisher","first-page":"419","DOI":"10.1146\/annurev-psych-010419-050837","article-title":"Implicit social cognition.","volume":"71","author":"Greenwald","year":"2020","journal-title":"Annu Rev Psychol"},{"issue":"1","key":"soi240113r35","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1037\/a0015575","article-title":"Understanding and using the Implicit Association Test: III. Meta-analysis of predictive validity.","volume":"97","author":"Greenwald","year":"2009","journal-title":"J Pers Soc Psychol"},{"key":"soi240113r29","unstructured":"National Institute on Minority Health and Health Disparities. HD Pulse interventions portal. 2024. Accessed November 8, 2024. https:\/\/hdpulse.nimhd.nih.gov\/interventions"}],"container-title":["JAMA Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamasurgery\/articlepdf\/2830621\/jamasurgery_kalbaugh_2025_oi_240113_1747170542.37609.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,5,14]],"date-time":"2025-05-14T15:03:32Z","timestamp":1747235012000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamasurgery\/fullarticle\/2830621"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,1]]},"references-count":35,"journal-issue":{"issue":"5","published-print":{"date-parts":[[2025,5,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamasurg.2024.7254","relation":{},"ISSN":["2168-6254"],"issn-type":[{"value":"2168-6254","type":"print"}],"subject":[],"published":{"date-parts":[[2025,5,1]]}}}