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Reid HW, Lin OM, Fabbro RL, Johnson KS, Svetkey LP, Olsen MK, Matsouaka RA, Chung ST, Batch BC. Racial differences in patient perception of interactions with providers are associated with health outcomes in type II diabetes. PATIENT EDUCATION AND COUNSELING 2021; 104:1993-2003. [PMID: 33579569 PMCID: PMC8217118 DOI: 10.1016/j.pec.2021.01.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Examine the association of patient perceptions of care with hemoglobin A1c (HbA1c), medication adherence, and missed appointments in non-Hispanic Black (NHB) and White (NHW) patients with type 2 diabetes (T2DM). METHODS We used linear and logistic regression models to analyze the association of the Interpersonal Processes of Care survey (IPC) with HbA1c, medication adherence, and missed appointments. We then examined how these associations differed by race. RESULTS There was no overall association between IPC subdomains and HbA1c in our sample (N = 221). NHB patients perceiving their provider always explained results and medications had a HbA1c on average 0.59 (-1.13, -0.04; p = 0.04) points lower than those perceiving their provider sometimes explained results and medications. No effect was observed in NHWs. Never perceiving disrespect from office staff was associated with an average 0.67 (-1.1, -0.24; p = 0.002) point improvement in medication adherence for all patients. Never perceiving discrimination from providers was associated with a 0.44 (-0.63, -0.25; p < 0.0001) decrease in the probability of missing an appointment for NHB patients. CONCLUSIONS These results demonstrate that particular aspects of communication in the patient-provider interaction may contribute to racial disparities in T2DM. PRACTICE IMPLICATIONS Communication training for both providers and staff may reduce disparities in T2DM.
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Affiliation(s)
| | | | | | - Kimberly S Johnson
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, Center for Aging and Human Development, Duke University School of Medicine, Geriatrics Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, USA
| | - Laura P Svetkey
- Department of Medicine, Division of Nephrology, Duke University School of Medicine, Durham, USA
| | - Maren K Olsen
- Duke University Department of Biostatistics and Bioinformatics, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, USA
| | - Roland A Matsouaka
- Duke University Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University, Durham, USA
| | | | - Bryan C Batch
- Department of Medicine, Division of Endocrinology, Duke University School of Medicine, Durham, USA
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Sonik RA, Creedon TB, Progovac AM, Carson N, Delman J, Delman D, Lê Cook B. Depression treatment preferences by race/ethnicity and gender and associations between past healthcare discrimination experiences and present preferences in a nationally representative sample. Soc Sci Med 2020; 253:112939. [PMID: 32276182 DOI: 10.1016/j.socscimed.2020.112939] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 03/12/2020] [Accepted: 03/15/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Depression treatment disparities are well documented. Differing treatment preferences across social groups have been suggested as a cause of these disparities. However, existing studies of treatment preferences have been limited to individuals currently receiving clinical care, and existing measures of depression treatment preferences have not accounted for factors that may be disproportionately relevant to the preferences of disparities populations. This study therefore aimed to assess depression treatment preferences by race/ethnicity and gender in a representative community sample, while accounting for access to healthcare, provider characteristics, and past experiences of discrimination in healthcare settings. METHODS We conducted a nationally representative study of individuals with depression in and out of clinical care. Treatment preferences (medication versus talk therapy) were elicited through a discrete choice experiment that accounted for tradeoffs with factors related to access and provider characteristics deemed relevant by community stakeholders. Past discrimination was assessed through questions about unfair treatment from medical providers and front desk staff due to personal characteristics (e.g., race, gender). We used conditional logit models to assess treatment preferences by race/ethnicity and gender and examined whether preferences were associated with past experiences of healthcare discrimination. RESULTS Non-Hispanic white respondents (OR-here, the odds of a talk therapy preference over the odds of a medication preference: 0.80, 95% CI: 0.64, 0.99) and men (OR 0.76, 95% CI: 0.60, 0.96) preferred medication over talk therapy, while non-Hispanic black respondents, Hispanic respondents, and women did not prefer one over the other. Past discrimination in healthcare settings was associated with lower preferences for talk therapy and greater preferences for medication, particularly among non-Hispanic black respondents and women respondents. CONCLUSIONS Addressing previous methodological limitations yielded estimates for depression treatment preferences by race/ethnicity and gender that differed from past studies. Also, past discrimination in healthcare settings was associated with current treatment preferences.
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Affiliation(s)
| | - Timothy B Creedon
- Health Equity Research Lab, Cambridge Health Alliance, Harvard Medical School, United States
| | - Ana Maria Progovac
- Health Equity Research Lab, Cambridge Health Alliance, Harvard Medical School, United States
| | - Nicholas Carson
- Health Equity Research Lab, Cambridge Health Alliance, Harvard Medical School, United States
| | | | | | - Benjamin Lê Cook
- Health Equity Research Lab, Cambridge Health Alliance, Harvard Medical School, United States
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- AltaMed Institute for Health Equity, United States
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Nanna MG, Navar AM, Zakroysky P, Xiang Q, Goldberg AC, Robinson J, Roger VL, Virani SS, Wilson PWF, Elassal J, Lee LV, Wang TY, Peterson ED. Association of Patient Perceptions of Cardiovascular Risk and Beliefs on Statin Drugs With Racial Differences in Statin Use: Insights From the Patient and Provider Assessment of Lipid Management Registry. JAMA Cardiol 2019; 3:739-748. [PMID: 29898219 DOI: 10.1001/jamacardio.2018.1511] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance African American individuals face higher atherosclerotic cardiovascular disease risk than white individuals; reasons for these differences, including potential differences in patient beliefs regarding preventive care, remain unknown. Objective To evaluate differences in statin use between white and African American patients and identify the potential causes for any observed differences. Design, Setting, and Participants Using the 2015 Patient and Provider Assessment of Lipid Management (PALM) Registry data, we compared statin use and dosing between African American and white outpatient adults who were potentially eligible for primary or secondary prevention statins. A total of 138 US community health care practices contributed to the data. Data analysis was conducted from March 2017 to May 2018. Main Outcomes and Measures Primary outcomes were use and dosing of statin therapy according to the 2013 American College of Cardiology/American Heart Association guideline by African American or white race. Secondary outcomes included lipid levels and patient-reported beliefs. Poisson regression was used to evaluate the association between race and statin undertreatment, a category combining people who were not taking a statin or those taking a dose intensity lower than recommended. Results A total of 5689 patients (806 [14.2%] African American) in the PALM registry were eligible for statin therapy. African American individuals were less likely than white individuals to be treated with a statin (570/807 [70.6%] vs 3654/4883 [74.8%]; P = .02). Among those treated, African American patients were less likely than white patients to receive a statin at guideline-recommended intensity (269 [33.3%] vs 2145 [43.9%], respectively; P < .001; relative risk, 1.07 [95% CI, 1.00-1.15]; P = .05, after adjustment for demographic and clinical factors). The median (interquartile range) low-density lipoprotein cholesterol levels of patients receiving treatment were higher among African American than white individuals (97.0 [76.0-121.0] mg/dL vs 85.0 [68.0-105.0] mg/dL; P < .001). African American individuals were less likely than white individuals to believe statins were safe (292 [36.2%] vs 2800 [57.3%]; P < .001) or effective (564 [70.0%] vs 3635 [74.4%]; P = .008) and were less likely to trust their clinician (663 [82.3%] vs 4579 [93.8%]; P < .001). Group differences in statin undertreatment were not significant after adjusting for demographic, clinical, and clinician factors, socioeconomic status, and patient beliefs (final adjusted relative risk, 1.03 [95% CI 0.96-1.11]; P = .35). Conclusions and Relevance African American individuals were less likely to receive guideline-recommended statin therapy. Demographic, clinical, socioeconomic, belief-related, and clinician differences contributed to observed differences and represent potential targets for intervention.
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Affiliation(s)
| | - Ann Marie Navar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Pearl Zakroysky
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Qun Xiang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | | | - Peter W F Wilson
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia.,Emory Clinical Cardiovascular Research Institute, Atlanta, Georgia
| | | | | | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Nathan CL, Gutierrez C. FACETS of health disparities in epilepsy surgery and gaps that need to be addressed. Neurol Clin Pract 2018; 8:340-345. [PMID: 30140586 DOI: 10.1212/cpj.0000000000000490] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 04/27/2018] [Indexed: 11/15/2022]
Abstract
Purpose of review Disparities in treatment and outcomes of patients with epilepsy have been identified in several distinct patient populations. The purpose of this review is to organize the literature and establish clear pathways as to why certain patient populations are not receiving epilepsy surgery. By establishing the acronym FACETS (fear of treatment, access to care, communication barriers, education, trust between patient and physician, and social support), we set up a pathway to further study this area in an organized fashion, hopefully leading to objective solutions. Recent findings Studies revealed that African American, Hispanic, and non-English-speaking patients underwent surgical treatment for epilepsy at rates significantly lower compared to white patients. Summary This article explains possible reasons outlined by FACETS for the health disparities in epilepsy surgery that exist in patients of a certain race, socioeconomic status, and language proficiency.
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Affiliation(s)
- Cody L Nathan
- Hospital of the University of Pennsylvania (CLN), Philadelphia; and Department of Neurology (CG), University of Maryland Medical Center, Baltimore
| | - Camilo Gutierrez
- Hospital of the University of Pennsylvania (CLN), Philadelphia; and Department of Neurology (CG), University of Maryland Medical Center, Baltimore
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Khan A, Furtak SL, Melvin P, Rogers JE, Schuster MA, Landrigan CP. Parent-Provider Miscommunications in Hospitalized Children. Hosp Pediatr 2017; 7:505-515. [PMID: 28768684 DOI: 10.1542/hpeds.2016-0190] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Miscommunications lead to medical errors and suboptimal hospital experience. Parent-provider miscommunications are understudied. OBJECTIVES (1) Examine characteristics of parent-provider miscommunications about hospitalized children, (2) describe associations among parent-provider miscommunications, parent-reported errors, and hospital experience, and (3) compare parent and attending physician reports of parent-provider miscommunications. METHODS Prospective cohort study of 471 parents of 0- to 17-year-old medical inpatients in a pediatric hospital between May 1, 2013 and October 1, 2014. At discharge, parents reported parent-provider miscommunication and type (selecting all applicable responses), overall experience, and errors during hospitalization. During discharge billing, the attending physicians (n = 52) of a subset of patients (n = 217) also reported miscommunications, enabling comparison of parent and attending physician reports. We used logistic regression to examine characteristics of parent-reported miscommunications; McNemar's test to examine associations between miscommunications, errors, and top-box (eg, "excellent") experience; and generalized estimating equations to compare parent- and attending physician-reported miscommunication rates. RESULTS Parents completed 406 surveys (86.2% response rate). 15.3% of parents (n = 62) reported miscommunications. Parents of patients with nonpublic insurance (odds ratio: 1.99; 95% confidence interval: 1.03-3.85) and longer lengths of stay (odds ratio: 1.12; 95% confidence interval: 1.02-1.23) more commonly reported miscommunications. Parents reporting miscommunications were 5.3 times more likely to report errors and 78.6% less likely to report top-box overall experience (P < .001 for both). Among patients with both parent and attending physician surveys, 16.1% (n = 35) of parents and 3.7% (n = 8) of attending physicians reported miscommunications (P < .001). Both parents and attending physicians attributed miscommunications most often to family receipt of conflicting information. CONCLUSIONS Parent-provider miscommunications were associated with parent-reported errors and suboptimal hospital experience. Parents reported parent-provider miscommunications more often than attending physicians did.
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Affiliation(s)
- Alisa Khan
- Division of General Pediatrics, .,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
| | | | | | - Jayne E Rogers
- Department of Nursing, Boston Children's Hospital, Boston, Massachusetts
| | - Mark A Schuster
- Division of General Pediatrics.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
| | - Christopher P Landrigan
- Division of General Pediatrics.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and.,Division of Sleep Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Nagarajan N, Rahman S, Boss EF. Are There Racial Disparities in Family-Reported Experiences of Care in Inpatient Pediatrics? Clin Pediatr (Phila) 2017; 56:619-626. [PMID: 27621079 DOI: 10.1177/0009922816668497] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite increased emphasis on patient satisfaction as a quality measure in health care, little is known about the influence of race in parent-reported experience of care in pediatrics. This study evaluates the association of race with patient satisfaction scores in an inpatient pediatric tertiary care hospital in one year. Risk-adjusted multivariable logistic regression was performed to evaluate the association of minority race with the likelihood to provide a top-box (=5) satisfaction score for 38 individual questions across 8 domains. Of the 904 participants, 269 (29.8%) identified as belonging to a minority race. Parents of minority children reported 30% to 50% lower satisfaction across questions related to well-established themes of interpersonal communication and cultural competency. Overall, minorities also reported lower satisfaction for the domain of nursing care (odds ratio 0.7, P = .016). These findings suggest a need for training and interventions to improve communication and mitigate disparities in how minority patients and their families perceive pediatric care.
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Affiliation(s)
- Neeraja Nagarajan
- 1 Johns Hopkins University School of Medicine, Baltimore, MD, USA.,2 Brigham and Women's Hospital, Boston, MA, USA
| | - Sydur Rahman
- 1 Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily F Boss
- 1 Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Kressin NR, Chapman SE, Magnani JW. A Tale of Two Patients: Patient-Centered Approaches to Adherence as a Gateway to Reducing Disparities. Circulation 2017; 133:2583-92. [PMID: 27297350 DOI: 10.1161/circulationaha.116.015361] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The disparate effects of social determinants of health on cardiovascular health status and health care have been extensively documented by epidemiology. Yet, very little attention has been paid to how understanding and addressing social determinants of health might improve the quality of clinical interactions, especially by improving patients' adherence to recommended therapies. We present a case and suggested approach to illustrate how cardiovascular clinicians can use patient-centered approaches to identify and address social determinants of health barriers to adherence and reduce the impact of unconscious clinician biases. We propose that cardiovascular clinicians (1) recognize that patients may have different belief systems about illnesses' cause and treatment, which may influence their actions, and not assume they share one's experiences or explanatory model; (2) Endeavor to understand the individual patient before you; (3) based on that understanding, tailor your approach to that individual. We suggest a previously-developed mnemonic for an approach to RESPECT the patient: First, show Respect; then elicit patients' understandings of their illness by asking about their Explanatory model. Ask about the patient's Social context, share Power in the interaction, show Empathy, ask about Concerns or fears, and work to develop Trust by building the relationship over time. We provide additional clinical resources to support these efforts, including lay descriptions of cardiovascular conditions, challenges to adherence, and suggested strategies to address them.
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Affiliation(s)
- Nancy R Kressin
- From VA Boston Healthcare System, Jamaica Plain, MA (N.R.K.); Department of Medicine, Boston University School of Medicine and Boston Medical Center, MA (N.R.K., S.E.C.); and Department of Medicine, Division of Cardiology, UPMC Heart & Vascular Institute, University of Pittsburgh, PA (J.W.M.).
| | - Sheila E Chapman
- From VA Boston Healthcare System, Jamaica Plain, MA (N.R.K.); Department of Medicine, Boston University School of Medicine and Boston Medical Center, MA (N.R.K., S.E.C.); and Department of Medicine, Division of Cardiology, UPMC Heart & Vascular Institute, University of Pittsburgh, PA (J.W.M.)
| | - Jared W Magnani
- From VA Boston Healthcare System, Jamaica Plain, MA (N.R.K.); Department of Medicine, Boston University School of Medicine and Boston Medical Center, MA (N.R.K., S.E.C.); and Department of Medicine, Division of Cardiology, UPMC Heart & Vascular Institute, University of Pittsburgh, PA (J.W.M.)
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Goldenberg A, Vujic I, Sanlorenzo M, Ortiz-Urda S. Melanoma risk perception and prevention behavior among African-Americans: the minority melanoma paradox. Clin Cosmet Investig Dermatol 2015; 8:423-9. [PMID: 26346576 PMCID: PMC4531028 DOI: 10.2147/ccid.s87645] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction Melanoma is the most deadly type of skin cancer with 75% of all skin cancer deaths within the US attributed to it. Risk factors for melanoma include ultraviolet exposure, genetic predisposition, and phenotypic characteristics (eg, fair skin and blond hair). Whites have a 27-fold higher incidence of melanoma than African-Americans (AA), but the 5-year survival is 17.8% lower for AA than Whites. It is reported continuously that AA have more advanced melanomas at diagnosis, and overall lower survival rates. This minority melanoma paradox is not well understood or studied. Objective To explore further, the possible explanations for the difference in melanoma severity and survival in AA within the US. Methods Qualitative review of the literature. Results Lack of minority-targeted public education campaigns, low self-risk perception, low self-skin examinations, intrinsic virulence, vitamin D differences, and physician mistrust may play a role in the melanoma survival disparity among AA. Conclusion Increases in public awareness of melanoma risk among AA through physician and media-guided education, higher index of suspicion among individuals and physicians, and policy changes can help to improve early detection and close the melanoma disparity gap in the future.
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Affiliation(s)
- Alina Goldenberg
- Department of Internal Medicine/Dermatology, University of California, San Diego, CA, USA
| | - Igor Vujic
- Mt Zion Cancer Research Center, University of California San Francisco, San Francisco, CA, USA ; Department of Dermatology, The Rudolfstiftung Hospital, Academic Teaching Hospital, Medical University Vienna, Vienna, Austria
| | - Martina Sanlorenzo
- Mt Zion Cancer Research Center, University of California San Francisco, San Francisco, CA, USA ; Section of Dermatology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Susana Ortiz-Urda
- Mt Zion Cancer Research Center, University of California San Francisco, San Francisco, CA, USA
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Paternotte E, van Dulmen S, van der Lee N, Scherpbier AJJA, Scheele F. Factors influencing intercultural doctor-patient communication: a realist review. PATIENT EDUCATION AND COUNSELING 2015; 98:420-45. [PMID: 25535014 DOI: 10.1016/j.pec.2014.11.018] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 10/23/2014] [Accepted: 11/17/2014] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Due to migration, doctors see patients from different ethnic backgrounds. This causes challenges for the communication. To develop training programs for doctors in intercultural communication (ICC), it is important to know which barriers and facilitators determine the quality of ICC. This study aimed to provide an overview of the literature and to explore how ICC works. METHODS A systematic search was performed to find literature published before October 2012. The search terms used were cultural, communication, healthcare worker. A realist synthesis allowed us to use an explanatory focus to understand the interplay of communication. RESULTS In total, 145 articles met the inclusion criteria. We found ICC challenges due to language, cultural and social differences, and doctors' assumptions. The mechanisms were described as factors influencing the process of ICC and divided into objectives, core skills and specific skills. The results were synthesized in a framework for the development of training. CONCLUSION The quality of ICC is influenced by the context and by the mechanisms. These mechanisms translate into practical points for training, which seem to have similarities with patient-centered communication. PRACTICE IMPLICATIONS Training for improving ICC can be developed as an extension of the existing training for patient-centered communication.
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Affiliation(s)
- Emma Paternotte
- Department of Healthcare Education, Sint Lucas Andreas hospital, Amsterdam, The Netherlands.
| | - Sandra van Dulmen
- NIVEL (Netherlands Institute for Health Services Research), Utrecht, The Netherlands; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands; Faculty of Health Sciences, Buskerud and Vestfold University College, Drammen, Norway.
| | - Nadine van der Lee
- Department of Healthcare Education, Sint Lucas Andreas hospital, Amsterdam, The Netherlands.
| | - Albert J J A Scherpbier
- Institute for Medical Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Fedde Scheele
- Medical School of Sciences, Vu University Medical Center, Amsterdam, The Netherlands.
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Zickmund SL, Burkitt KH, Gao S, Stone RA, Rodriguez KL, Switzer GE, Shea JA, Bayliss NK, Meiksin R, Walsh MB, Fine MJ. Racial Differences in Satisfaction with VA Health Care: A Mixed Methods Pilot Study. J Racial Ethn Health Disparities 2015; 2:317-29. [PMID: 26863462 DOI: 10.1007/s40615-014-0075-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/24/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION As satisfied patients are more adherent and play a more active role in their own care, a better understanding of factors associated with patient satisfaction is important. PURPOSE In response to a United States Veterans Administration (VA) Hospital Report Card that revealed lower levels of satisfaction with health care for African Americans compared to Whites, we conducted a mixed methods pilot study to obtain preliminary qualitative and quantitative information about possible underlying reasons for these racial differences. METHODS We conducted telephone interviews with 30 African American and 31 White veterans with recent inpatient and/or outpatient health care visits at three urban VA Medical Centers. We coded the qualitative interviews in terms of identified themes within defined domains. We summarized racial differences using ordinal logistic regression for Likert scale outcomes and used random effects logistic regression to assess racial differences at the domain level. RESULTS Compared to Whites, African Americans were younger (p < 0.001) and better educated (p = 0.04). Qualitatively, African Americans reported less satisfaction with trust/confidence in their VA providers and healthcare system and less satisfaction with patient-provider communication. Quantitatively, African Americans reported less satisfaction with outpatient care (odds ratio = 0.28; 95 % confidence interval (CI) 0.10-0.82), but not inpatient care. At the domain level, African Americans were significantly less likely than Whites to express satisfaction themes in the domain of trust/confidence (odds ratio = 0.36; 95 % CI 0.18-0.73). CONCLUSION The current pilot study demonstrates racial differences in satisfaction with outpatient care and identifies some specific sources of dissatisfaction. Future research will include a large national cohort, including Hispanic veterans, in order to gain further insight into the sources of racial and ethnic differences in satisfaction with VA care and inform future interventions.
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Affiliation(s)
- Susan L Zickmund
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA. .,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA.
| | - Kelly H Burkitt
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA
| | - Shasha Gao
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA
| | - Roslyn A Stone
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA.,Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, 15261, USA
| | - Keri L Rodriguez
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA
| | - Galen E Switzer
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
| | - Judy A Shea
- Philadelphia VA Medical Center, Center for Health Equity Research and Promotion, Philadelphia, PA, 19104, USA
| | - Nichole K Bayliss
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA.,Department of Psychology, Chatham University, Pittsburgh, PA, 15232, USA
| | - Rebecca Meiksin
- Gender Violence and Health Centre, London School of Hygiene and Tropical Medicine, London, England
| | - Mary B Walsh
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA
| | - Michael J Fine
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA
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12
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Zullig LL, Shaw RJ, Shah BR, Peterson ED, Lindquist JH, Crowley MJ, Grambow SC, Bosworth HB. Patient-provider communication, self-reported medication adherence, and race in a postmyocardial infarction population. Patient Prefer Adherence 2015; 9:311-8. [PMID: 25737633 PMCID: PMC4344178 DOI: 10.2147/ppa.s75393] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Our objectives were to: 1) describe patient-reported communication with their provider and explore differences in perceptions of racially diverse adherent versus nonadherent patients; and 2) examine whether the association between unanswered questions and patient-reported medication nonadherence varied as a function of patients' race. METHODS We conducted a cross-sectional analysis of baseline in-person survey data from a trial designed to improve postmyocardial infarction management of cardiovascular disease risk factors. RESULTS Overall, 298 patients (74%) reported never leaving their doctor's office with unanswered questions. Among those who were adherent and nonadherent with their medications, 183 (79%) and 115 (67%) patients, respectively, never left their doctor's office with unanswered questions. In multivariable logistic regression, although the simple effects of the interaction term were different for patients of nonminority race (odds ratio [OR]: 2.16; 95% confidence interval [CI]: 1.19-3.92) and those of minority race (OR: 1.19; 95% CI: 0.54-2.66), the overall interaction effect was not statistically significant (P=0.24). CONCLUSION The quality of patient-provider communication is critical for cardiovascular disease medication adherence. In this study, however, having unanswered questions did not impact medication adherence differently as a function of patients' race. Nevertheless, there were racial differences in medication adherence that may need to be addressed to ensure optimal adherence and health outcomes. Effort should be made to provide training opportunities for both patients and their providers to ensure strong communication skills and to address potential differences in medication adherence in patients of diverse backgrounds.
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Affiliation(s)
- Leah L Zullig
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Duke University, Durham, NC, USA
- Correspondence: Leah L Zullig, Durham Center for Health Services Research in Primary Care, 411 West Chapel Hill Street, Suite 600, Durham, NC 27701, USA, Tel +1 919 286 0411 ext 7586, Fax +1 919 416 5839, Email
| | - Ryan J Shaw
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
- School of Nursing, Duke University, Durham, NC, USA
| | - Bimal R Shah
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University Durham, NC, USA
| | - Eric D Peterson
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University Durham, NC, USA
| | - Jennifer H Lindquist
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Matthew J Crowley
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Duke University, Durham, NC, USA
| | - Steven C Grambow
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Duke University, Durham, NC, USA
- School of Nursing, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
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13
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Oldroyd JC, Levinson MR, Stephenson G, Rouse A, Leeuwrik T. A focus group study investigating medical decision making in octogenarians of high socioeconomic status with successful outcomes following cardiac surgery. Australas J Ageing 2013; 33:174-9. [DOI: 10.1111/ajag.12022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- John C Oldroyd
- Cabrini Hospital; Melbourne Victoria Australia
- International Public Health Unit; Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Michele R Levinson
- Cabrini Hospital; Melbourne Victoria Australia
- Cabrini-Monash Department of Medicine; Monash University; Melbourne Victoria Australia
| | | | - Alice Rouse
- Department of Medicine; Monash University; Melbourne Victoria Australia
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14
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Blair IV, Steiner JF, Fairclough DL, Hanratty R, Price DW, Hirsh HK, Wright LA, Bronsert M, Karimkhani E, Magid DJ, Havranek EP. Clinicians' implicit ethnic/racial bias and perceptions of care among Black and Latino patients. Ann Fam Med 2013; 11:43-52. [PMID: 23319505 PMCID: PMC3596038 DOI: 10.1370/afm.1442] [Citation(s) in RCA: 252] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We investigated whether clinicians' explicit and implicit ethnic/racial bias is related to black and Latino patients' perceptions of their care in established clinical relationships. METHODS We administered a telephone survey to 2,908 patients, stratified by ethnicity/race, and randomly selected from the patient panels of 134 clinicians who had previously completed tests of explicit and implicit ethnic/racial bias. Patients completed the Primary Care Assessment Survey, which addressed their clinicians' interpersonal treatment, communication, trust, and contextual knowledge. We created a composite measure of patient-centered care from the 4 subscales. RESULTS Levels of explicit bias were low among clinicians and unrelated to patients' perceptions. Levels of implicit bias varied among clinicians, and those with greater implicit bias were rated lower in patient-centered care by their black patients as compared with a reference group of white patients (P = .04). Latino patients gave the clinicians lower ratings than did other groups (P <.0001), and this did not depend on the clinicians' implicit bias (P = .98). CONCLUSIONS This is among the first studies to investigate clinicians' implicit bias and communication processes in ongoing clinical relationships. Our findings suggest that clinicians' implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes. As such, this finding supports the Institute of Medicine's suggestion that clinician bias may contribute to health disparities. Latinos' overall greater concerns about their clinicians appear to be based on aspects of care other than clinician bias.
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Affiliation(s)
- Irene V Blair
- Department of Psychology and Neuro-science, University of Colorado Boulder, 80309-0345, USA.
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15
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Abstract
Racial, ethnic, and gender disparities in health outcomes are a major challenge for the US health care system. Although the causes of these disparities are multifactorial, unconscious bias on the part of health care providers plays a role. Unconscious bias occurs when subconscious prejudicial beliefs about stereotypical individual attributes result in an automatic and unconscious reaction and/or behavior based on those beliefs. This article reviews the evidence in support of unconscious bias and resultant disparate health outcomes. Although unconscious bias cannot be entirely eliminated, acknowledging it, encouraging empathy, and understanding patients' sociocultural context promotes just, equitable, and compassionate care to all patients.
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Affiliation(s)
- Heena P Santry
- Department of Surgery, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA.
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16
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How well do doctors know their patients? Factors affecting physician understanding of patients' health beliefs. J Gen Intern Med 2011; 26:21-7. [PMID: 20652759 PMCID: PMC3024116 DOI: 10.1007/s11606-010-1453-3] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 06/11/2010] [Accepted: 06/29/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND An important feature of patient-centered care is physician understanding of their patients' health beliefs and values. OBJECTIVE Determine physicians' awareness of patients' health beliefs as well as communication, relationship, and demographic factors associated with better physician understanding of patients' illness perspectives. DESIGN Cross-sectional, observational study. RESEARCH PARTICIPANTS: A convenience sample of 207 patients and 29 primary care physicians from 10 outpatient clinics. APPROACH AND MEASURES: After their consultation, patients and physicians independently completed the CONNECT instrument, a measure that assesses beliefs about the degree to which the patient's condition has a biological cause, is the patient's fault, is one the patient can control, has meaning for the patient, can be treated with natural remedies, and patient preferences for a partnership with the physician. Physicians completed the measure again on how they thought the patient responded. Active patient participation (frequency of questions, concerns, acts of assertiveness) was coded from audio-recordings of the consultations. Physicians' answers for how they thought the patient responded to the health belief measure were compared to their patients' actual responses. Degree of physician understanding of patients' health beliefs was computed as the absolute difference between patients' health beliefs and physicians' perception of patients' health beliefs. KEY RESULTS Physicians' perceptions of their patients' health beliefs differed significantly (P<0.001) from patients' actual beliefs. Physicians also thought patients' beliefs were more aligned with their own. Physicians had a better understanding of the degree to which patients believed their health conditions had personal meaning (p=0.001), would benefit from natural remedies (p=0.049), were conditions the patient could control (p=0.001), and wanted a partnership with the doctor (p=0.014) when patients more often asked questions, expressed concerns, and stated their opinions. Physicians were poorer judges of patients' beliefs when patients were African-American (desire for partnership) (p=0.013), Hispanic (meaning) (p=0.075), or of a different race (sense of control) (p=0.024). CONCLUSIONS Physicians were not good judges of patient's health beliefs, but had a substantially better understanding when patients more actively participated in the consultation. Strategies for increasing physicians' awareness of patients' health beliefs include preconsultation assessment of patients' beliefs, implementing culturally appropriate patient activation programs, and greater use of partnership-building to encourage active patient participation.
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Shih G, Turok DK, Parker WJ. Vasectomy: the other (better) form of sterilization. Contraception 2010; 83:310-5. [PMID: 21397087 DOI: 10.1016/j.contraception.2010.08.019] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 08/25/2010] [Accepted: 08/25/2010] [Indexed: 11/30/2022]
Abstract
Male sterilization (vasectomy) is the most effective form and only long-acting form of contraception available to men in the United States. Compared to female sterilization, it is more efficacious, more cost-effective, and has lower rates of complications. Despite these advantages, in the United States, vasectomy is utilized at less than half the rate of female sterilization. In addition, vasectomy is least utilized among black and Latino populations, groups with the highest rates of female sterilization. This review provides an overview of vasectomy use and techniques, and explores reasons for the disparity in vasectomy utilization in the United States.
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Affiliation(s)
- Grace Shih
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA 94110, USA.
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Ayotte BJ, Kressin NR. Race differences in cardiac catheterization: the role of social contextual variables. J Gen Intern Med 2010; 25:814-8. [PMID: 20383600 PMCID: PMC2896597 DOI: 10.1007/s11606-010-1324-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 01/28/2010] [Accepted: 02/12/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Race differences in the receipt of invasive cardiac procedures are well-documented but the etiology remains poorly understood. OBJECTIVE We examined how social contextual variables were related to race differences in the likelihood of receiving cardiac catheterization in a sample of veterans who were recommended to undergo the procedure by a physician. DESIGN Prospective observational cohort study. PARTICIPANTS A subsample from a study examining race disparities in cardiac catheterization of 48 Black/African American and 189 White veterans who were recommended by a physician to undergo cardiac catheterization. MEASURES We assessed social contextual variables (e.g., knowing somebody who had the procedure, being encouraged by family or friends), clinical variables (e.g., hypertension, maximal medical therapy), and if participants received cardiac catheterization at any point during the study. KEY RESULTS Blacks/African Americans were less likely to undergo cardiac catheterization compared to Whites even after controlling for age, education, and clinical variables (OR = 0.31; 95% CI, 0.13, 0.75). After controlling for demographic and clinical variables, three social contextual variables were significantly related to increased likelihood of receiving catheterization: knowing someone who had undergone the procedure (OR = 3.14; 95% CI, 1.70, 8.74), social support (OR = 2.05; 95% CI, 1.17, 2.78), and being encouraged by family to have procedure (OR = 1.45; 95% CI, 1.08, 1.90). After adding the social contextual variables, race was no longer significantly related to the likelihood of receiving catheterization, thus suggesting that social context plays an important role in the relationship between race and cardiac catheterization. CONCLUSIONS Our results suggest that social contextual factors are related to the likelihood of receiving recommended care. In addition, accounting for these relationships attenuated the observed race disparities between Whites and Blacks/African Americans who were recommended to undergo cardiac catheterization by their physicians.
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Affiliation(s)
- Brian J Ayotte
- Center for Organizational, Leadership, and Management Research, VA Boston Healthcare System, Boston, MA, USA.
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19
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Sorkin DH, Ngo-Metzger Q, De Alba I. Racial/ethnic discrimination in health care: impact on perceived quality of care. J Gen Intern Med 2010; 25:390-6. [PMID: 20146022 PMCID: PMC2855001 DOI: 10.1007/s11606-010-1257-5] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Revised: 12/23/2009] [Accepted: 01/07/2010] [Indexed: 12/02/2022]
Abstract
BACKGROUND Racial/ethnic minorities are more likely to report receipt of lower quality of health care; however, the mediators of such patient reports are not known. OBJECTIVES To determine (1) whether racial disparities in perceptions of quality of health care are mediated by perceptions of being discriminated against while receiving medical care and (2) whether this association is further mediated by patient sociodemographic characteristics, access to care, and patient satisfaction across racial/ethnic groups. RESEARCH DESIGN A cross-sectional analysis of a population-based sample of California adults responding to the 2003 California Health Interview Survey. Multivariable logistic regression was used to examine the relationship between perceived discrimination and perceived quality of health care after adjusting for patient characteristics and reports of access to care. MAIN RESULTS A total of 36,831 respondents were included. African Americans (68.7%) and Asian/Pacific Islanders (64.5%) were less likely than non-Hispanic whites (72.8%) and Hispanics (74.9%) to rate their health care quality highly. African Americans (13.1%) and Hispanics (13.4%) were the most likely to report discrimination, followed by Asian/Pacific Islanders (7.3%) and non-Hispanic whites (2.6%). Racial/ethnic discrimination in health care was negatively associated with ratings of health care quality within each racial/ethnic group, even after adjusting for sociodemographic variables and other indicators of access and satisfaction. Feeling discriminated against fully accounted for the difference in low ratings of quality care between African Americans and whites, but not for other racial/ethnic minorities. CONCLUSIONS Patient perceptions of discrimination may play an important, yet variable role in ratings of health care quality across racial/ethnic minority groups. Health care institutions should consider how to address this patient concern as a part of routine quality improvement.
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Affiliation(s)
- Dara H Sorkin
- Division of General Internal Medicine and Primary Care and the Health Policy Research Institute, University of California, Irvine School of Medicine, 100 Theory, Suite 110, Irvine, CA 92697-5800, USA.
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20
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Hammond WP. Psychosocial correlates of medical mistrust among African American men. AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY 2010; 45:87-106. [PMID: 20077134 PMCID: PMC2910212 DOI: 10.1007/s10464-009-9280-6] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
The current study proposed and tested a conceptual model of medical mistrust in a sample of African American men (N = 216) recruited primarily from barbershops in the Midwest and Southeast regions of the United States. Potential psychosocial correlates were grouped into background factors, masculine role identity/socialization factors, recent healthcare experiences, recent socioenvironmental experiences (e.g., discrimination), and healthcare system outcome expectations (e.g., perceived racism in healthcare). Direct and mediated relationships were assessed. Results from the hierarchical regression analyses suggest that perceived racism in healthcare was the most powerful correlate of medical mistrust even after controlling for other factors. Direct effects were found for age, masculine role identity, recent patient-physician interaction quality, and discrimination experiences. Also, perceived racism in healthcare mediated the relationship between discrimination experiences and medical mistrust. These findings suggest that African American men's mistrust of healthcare organizations is related to personal characteristics, previous negative social/healthcare experiences, and expectations of disparate treatment on the basis of race. These findings also imply that aspects of masculine role identity shape the tone of patient-physician interactions in ways that impede trust building processes.
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Affiliation(s)
- Wizdom Powell Hammond
- Department of Health Behavior Health Education, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC 27599, USA.
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Pollak KI, Arnold R, Alexander SC, Jeffreys AS, Olsen MK, Abernethy AP, Rodriguez KL, Tulsky JA. Do patient attributes predict oncologist empathic responses and patient perceptions of empathy? Support Care Cancer 2009; 18:1405-11. [PMID: 19838742 DOI: 10.1007/s00520-009-0762-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Accepted: 10/05/2009] [Indexed: 11/30/2022]
Abstract
PURPOSE Most patients with advanced cancer experience negative emotion. When patients express emotions, oncologists rarely respond empathically. Oncologists may respond more empathically to some patients, and patients may perceive different levels of empathy and trust given past documentation of disparities in cancer care. METHODS We audio-recorded 264 outpatient encounters between oncologists and patients with advanced cancer at three sites. We examined whether patient gender, age, race, marital status, education, economic security, and length of relationship with oncologist were related to oncologist empathic responses to patient's negative emotion and patient's perceptions of oncologist empathy and trust. RESULTS Half (51%) of the patients expressed a negative emotion. Oncologists sometimes responded with empathy (29%). Oncologists were equally empathic with all patients, except they were more empathic with patients with low economic security compared with those reporting high economic security (p = .002). Patients with low economic security viewed oncologists as more empathic (p = .06) compared with those with moderate security. Married patients also viewed oncologists as more empathic (p = .04). Patients who knew their oncologist for more than a year had more trust than patients who knew their oncologists for less time (p = .02). CONCLUSIONS Oncologists, in general, did not respond empathically to patient's negative emotion, and did this equally for most patients. Oncologists responded more empathically to patients who were less economically advantaged. In turn, patients with lower economic security perceived more empathy. Although oncologists need more education in responding empathically, they may not need to correct many biases in care.
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Affiliation(s)
- Kathryn I Pollak
- Duke Comprehensive Cancer Center, Cancer Prevention, Detection and Control Research Program, Duke University School of Medicine, Durham, USA.
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Kayaniyil S, Gravely-Witte S, Stewart DE, Higginson L, Suskin N, Alter D, Grace SL. Degree and correlates of patient trust in their cardiologist. J Eval Clin Pract 2009; 15:634-40. [PMID: 19522723 PMCID: PMC2972247 DOI: 10.1111/j.1365-2753.2008.01064.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
RATIONALE AND OBJECTIVES Trust in one's doctor has been associated with increased treatment adherence, patient satisfaction and improved health status. This study investigated the level and correlates of patient trust in their cardiac specialist. METHODS All 386 urban cardiologists in Southern Ontario (95 participating, response rate = 30%) were approached to recruit a sample of their coronary artery disease outpatients. A total of 1111 recent and consecutive patients consented to participate (approximately 13 patients per cardiologist, 317 female (26.7%); response rate = 60%), and clinical data were extracted from their medical charts. Participants completed a mailed survey including the Trust in Physicians scale, in addition to an assessment of socio-demographic, clinical and psychosocial correlates. RESULTS The mean trust score was equivalent to that reported in studies of primary care patients. Results of the significant multivariate model (F = 7.631, P < 0.001) revealed that less education (P < 0.001), higher systolic blood pressure (P = 0.022), less perceived cyclical/unpredictable illness timeline (P = 0.007) and greater perceived personal control over their heart condition (P = 0.004), were significant correlates of greater trust in cardiologist care. CONCLUSIONS The significance of education is corroborated by findings of lower satisfaction with cardiac care among those of higher socio-economic status, despite having generally greater access to care in Ontario. Moreover, the relationship between hypertension and greater trust may suggest that such perceptions are not based on doctor competence. Future studies should further investigate the correlates of trust, as well as the impact of trust on cardiac health outcomes.
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Affiliation(s)
- Sheena Kayaniyil
- Department of Kinesiology and Health Science, York University, Toronto, Canada
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23
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Armstrong K, McMurphy S, Dean LT, Micco E, Putt M, Halbert CH, Schwartz JS, Sankar P, Pyeritz RE, Bernhardt B, Shea JA. Differences in the patterns of health care system distrust between blacks and whites. J Gen Intern Med 2008; 23:827-33. [PMID: 18299939 PMCID: PMC2517897 DOI: 10.1007/s11606-008-0561-9] [Citation(s) in RCA: 195] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2007] [Revised: 01/26/2008] [Accepted: 02/06/2008] [Indexed: 01/26/2023]
Abstract
CONTEXT Although health care-related distrust may contribute to racial disparities in health and health care in the US, current evidence about racial differences in distrust is often conflicting, largely limited to measures of physician trust, and rarely linked to multidimensional trust or distrust. OBJECTIVE To test the hypothesis that racial differences in health care system distrust are more closely linked to values distrust than to competence distrust. DESIGN Cross-sectional telephone survey. PARTICIPANTS Two hundred fifty-five individuals (144 black, 92 white) who had been treated in primary care practices or the emergency department of a large, urban Mid-Atlantic health system. PRIMARY MEASURES Race, scores on the overall health care system distrust scale and on the 2 distrust subscales, values distrust and competence distrust. RESULTS In univariate analysis, overall health care system distrust scores were slightly higher among blacks than whites (25.8 vs 24.1, p = .05); however, this difference was driven by racial differences in values distrust scores (15.4 vs 13.8, p = .003) rather than in competence distrust scores (10.4 vs 10.3, p = .85). After adjustment for socioeconomic status, health/psychological status, and health care access, individuals in the top quartile of values distrust were significantly more likely to be black (odds ratio = 2.60, 95% confidence interval = 1.03-6.58), but there was no significant association between race and competence distrust. CONCLUSIONS Racial differences in health care system distrust are complex with far greater differences seen in the domain of values distrust than in competence distrust. This framework may be useful for explaining the mixed results of studies of race and health care-related distrust to date, for the design of future studies exploring the causes of racial disparities in health and health care, and for the development and testing of novel strategies for reducing these disparities.
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Affiliation(s)
- Katrina Armstrong
- Department of Medicine, School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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24
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Saha S, Freeman M, Toure J, Tippens KM, Weeks C, Ibrahim S. Racial and ethnic disparities in the VA health care system: a systematic review. J Gen Intern Med 2008; 23:654-71. [PMID: 18301951 PMCID: PMC2324157 DOI: 10.1007/s11606-008-0521-4] [Citation(s) in RCA: 201] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Revised: 11/29/2007] [Accepted: 01/04/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To better understand the causes of racial disparities in health care, we reviewed and synthesized existing evidence related to disparities in the "equal access" Veterans Affairs (VA) health care system. METHODS We systematically reviewed and synthesized evidence from studies comparing health care utilization and quality by race within the VA. RESULTS Racial disparities in the VA exist across a wide range of clinical areas and service types. Disparities appear most prevalent for medication adherence and surgery and other invasive procedures, processes that are likely to be affected by the quantity and quality of patient-provider communication, shared decision making, and patient participation. Studies indicate a variety of likely root causes of disparities including: racial differences in patients' medical knowledge and information sources, trust and skepticism, levels of participation in health care interactions and decisions, and social support and resources; clinician judgment/bias; the racial/cultural milieu of health care settings; and differences in the quality of care at facilities attended by different racial groups. CONCLUSIONS Existing evidence from the VA indicates several promising targets for interventions to reduce racial disparities in the quality of health care.
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25
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Fenta H, Hyman I, Noh S. Health service utilization by Ethiopian immigrants and refugees in Toronto. J Immigr Minor Health 2007; 9:349-57. [PMID: 17380388 DOI: 10.1007/s10903-007-9043-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to examine the health service utilization patterns of Ethiopian immigrants and refugees in a random sample of 342 adults residing in Toronto. The results suggested that 85% of the study participants used one or more type of health services, most often from a family physician. However, only 12.5% of them with a mental disorder received services from formal healthcare providers, mainly family physicians. While the presence of somatic symptoms was significantly associated with increased use of healthcare (p < 0.05), having a mental disorder was associated with lower rate of health service use (p < 0.05). These findings suggest that family physicians could play important role in identifying and treating Ethiopian clients who present with somatic symptoms, as these symptoms may reflect mental health problems. Further research is necessary to determine the reasons for the low rates of mental health services use in this population.
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Affiliation(s)
- Haile Fenta
- Social Equity and Health Research, Centre for Addiction and Mental Health, Toronto, ON, Canada.
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26
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Valverde EE, Waldrop-Valverde D, Anderson-Mahoney P, Loughlin AM, Del Rio C, Metsch L, Gardner LI. System and patient barriers to appropriate HIV care for disadvantaged populations: the HIV medical care provider perspective. J Assoc Nurses AIDS Care 2006; 17:18-28. [PMID: 16829359 DOI: 10.1016/j.jana.2006.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Little is known about the perception of system and patient barriers to adequate HIV care by an essential resource in the provision of HIV care, HIV medical care providers. To evaluate such perceptions, between November 2000 and June 2001 a survey was mailed to 526 HIV medical care providers who cared for HIV-infected individuals in Atlanta, Baltimore, Los Angeles, and Miami. Logistic regression analysis of survey results revealed significant differences in perceptions of system barriers between Black and Hispanic providers versus White providers and non-medical doctor providers versus medical doctor providers. Female providers differed significantly from male providers in assessing the importance of certain system and patient barriers. The authors observed that there are seeming disparities in perceptions of system and patient barriers to HIV medical care by providers of different race/ethnic groups, genders, and professions. More research needs to be conducted to determine if these disparities reflect differences in the provision of adequate HIV care for disadvantaged individuals.
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Affiliation(s)
- Eduardo E Valverde
- Department of Epidemiology and Public Health, University of Miami School of Medicine, Drenna Waldrop-Valverde, USA
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27
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Dy SM, Sharkey P, Herbert R, Haddad K, Wu AW. Comorbid illnesses and health care utilization among Medicare beneficiaries with lung cancer. Crit Rev Oncol Hematol 2006; 59:218-25. [PMID: 16829124 PMCID: PMC9676069 DOI: 10.1016/j.critrevonc.2006.04.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Revised: 03/30/2006] [Accepted: 04/20/2006] [Indexed: 10/24/2022] Open
Abstract
We evaluated the association of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) with outcomes in a 5% Medicare sample of 4447 elderly beneficiaries with lung cancer. Twenty-nine percent of patients had COPD and 13% had CHF. Patients with COPD or CHF had significantly decreased survival (hazard ratios 1.14 (1.05-1.25) and 1.38 (1.18-1.62), respectively); most of this differential was within 2 months after diagnosis. Patients with COPD or CHF were significantly less likely to receive surgery or chemotherapy than patients with neither COPD nor CHF. The association with less chemotherapy was similar in patients with the highest probability of surviving more than 2 months after the cancer diagnosis. In Medicare beneficiaries with lung cancer, COPD and CHF were common and were associated with both short-term mortality and decreased use of cancer treatments. Accounting for these two comorbid illnesses is important in evaluating health care utilization in this population.
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Affiliation(s)
- Sydney M Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Cooper LA, Beach MC, Johnson RL, Inui TS. Delving below the surface. Understanding how race and ethnicity influence relationships in health care. J Gen Intern Med 2006; 21 Suppl 1:S21-7. [PMID: 16405705 PMCID: PMC1484840 DOI: 10.1111/j.1525-1497.2006.00305.x] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
There is increasing evidence that racial and ethnic minority patients receive lower quality interpersonal care than white patients. Therapeutic relationships constitute the interpersonal milieu in which patients are diagnosed, given treatment recommendations, and referred for tests, procedures, or care by consultants in the health care system. This paper provides a review and perspective on the literature that explores the role of relationships and social interactions across racial and ethnic differences in health care. First, we examine the social and historical context for examining differences in interpersonal treatment in health care along racial and ethnic lines. Second, we discuss selected studies that examine how race and ethnicity influence clinician-patient relationships. While less is known about how race and ethnicity influence clinician-community, clinician-clinician, and clinician-self relationships, we briefly examine the potential roles of these relationships in overcoming disparities in health care. Finally, we suggest directions for future research on racial and ethnic health care disparities that uses a relationship-centered paradigm.
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Affiliation(s)
- Lisa A Cooper
- Welch Center for Prevention, Epidemiology, & Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
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Nápoles-Springer AM, Santoyo J, Houston K, Pérez-Stable EJ, Stewart AL. Patients' perceptions of cultural factors affecting the quality of their medical encounters. Health Expect 2005; 8:4-17. [PMID: 15713166 PMCID: PMC5060265 DOI: 10.1111/j.1369-7625.2004.00298.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The aim of this study was to identify key domains of cultural competence from the perspective of ethnically and linguistically diverse patients. DESIGN The study involved one-time focus groups in community settings with 61 African-Americans, 45 Latinos and 55 non-Latino Whites. Participants' mean age was 48 years, 45% were women, and 47% had less than a high school education. Participants in 19 groups were asked the meaning of 'culture' and what cultural factors influenced the quality of their medical encounters. Each text unit (TU or identifiable continuous verbal utterance) of focus group transcripts was content analysed to identify key dimensions using inductive and deductive methods. The proportion of TUs was calculated for each dimension by ethnic group. RESULTS Definitions of culture common to all three ethnic groups included value systems (25% of TUs), customs (17%), self-identified ethnicity (15%), nationality (11%) and stereotypes (4%). Factors influencing the quality of medical encounters common to all ethnic groups included sensitivity to complementary/alternative medicine (17%), health insurance-based discrimination (12%), social class-based discrimination (9%), ethnic concordance of physician and patient (8%), and age-based discrimination (4%). Physicians' acceptance of the role of spirtuality (2%) and of family (2%), and ethnicity-based discrimination (11%) were cultural factors specific to non-Whites. Language issues (21%) and immigration status (5%) were Latino-specific factors. CONCLUSIONS Providing quality health care to ethnically diverse patients requires cultural flexibility to elicit and respond to cultural factors in medical encounters. Interventions to reduce disparities in health and health care in the USA need to address cultural factors that affect the quality of medical encounters.
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Affiliation(s)
- Anna M Nápoles-Springer
- Medical Effectiveness Research Center for Diverse Populations and the Center on Aging in Diverse Communities, University of California San Francisco (UCSF), San Francisco, CA 94118-1944,
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Woodard LD, Hernandez MT, Lees E, Petersen LA. Racial differences in attitudes regarding cardiovascular disease prevention and treatment: a qualitative study. PATIENT EDUCATION AND COUNSELING 2005; 57:225-31. [PMID: 15911197 DOI: 10.1016/j.pec.2004.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2003] [Revised: 05/21/2004] [Accepted: 06/05/2004] [Indexed: 05/02/2023]
Abstract
The objective of this study was to explore coronary heart disease (CHD) health care experiences and beliefs of African-American and white patients to elicit potential causes of racial disparities in CHD outcomes. Twenty-four patients (14 white, 10 African-American) with established CHD participated in one of four focus groups. Using qualitative methods, verbatim transcripts of the groups were analyzed by independent investigators to identify key themes. We identified four themes: risk factor knowledge, physician--patient relationship, medical system access, and treatment beliefs. Racial differences were apparent in the experience of racism as a stress, knowledge of specifics of CHD risk factors, and assertiveness in the physician--patient relationship. These findings suggest that strategies to improve risk factor knowledge and to enable African-American patients to become active partners in their medical care may lead to improved CHD morbidity and mortality in this population. The efficacy of such interventions would need to be tested in further work.
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Affiliation(s)
- Lechauncy D Woodard
- Houston Center for Quality of Care and Utilization Studies, Department of Veterans Affairs, Health Services Research and Development Center of Excellence, Houston Veterans Affairs Medical Center, Houston, TX 77030, USA.
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Abstract
PURPOSE Few studies have attempted to link patients' beliefs about racism in the health care system with how they use and experience health care. METHODS Using telephone survey data from a national sample of 1,479 whites, 1,189 African Americans, and 983 Latinos, we explored patients' beliefs about racism, their preferences for the race and ethnicity of their physician, and their satisfaction with that physician. A scale was developed to reflect patients' beliefs about racism. Race-stratified analyses assessed associations between patients' beliefs, racial preferences for physicians, choice of physician, and satisfaction with care. RESULTS Among African Americans, stronger beliefs about racial discrimination in health care were associated with preferring an African American physician (P <.001). Whereas only 22% of African Americans preferred an African American physician, those who preferred a African American physician and had an African American physician were more likely to rate their physician as excellent than did African Americans who preferred a African American physician but had a non-African American physician (57% vs 20%, P <.001). Latinos with stronger beliefs about discrimination in health care were more likely to prefer a Latino physician (P <.001). One third of Latinos preferred a Latino physician. Though not statistically significant, those who preferred and had a Latino physician rated their physician higher than Latinos who preferred a Latino physician but had a non-Latino physician (40% vs 29%). CONCLUSIONS Many African Americans and Latinos perceive racism in the health care system, and those who do are more likely to prefer a physician of their own race or ethnicity. African Americans who have preferences are more often satisfied with their care when their own physicians match their preferences.
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Steyerberg EW, Earle CC, Neville BA, Weeks JC. Racial Differences in Surgical Evaluation, Treatment, and Outcome of Locoregional Esophageal Cancer: A Population-Based Analysis of Elderly Patients. J Clin Oncol 2005; 23:510-7. [PMID: 15659496 DOI: 10.1200/jco.2005.05.169] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose We investigated racial disparities in access to surgical evaluation, receipt of surgery, and survival among elderly patients with locoregional esophageal cancer. Methods We selected 2,946 white patients and 367 black patients who were older than 65 years and had clinically locoregional esophageal cancer in the Surveillance, Epidemiology, and End Results (SEER) registry (1991 to 1999). Treatment and outcome data were obtained from the linked SEER-Medicare databases. We used logistic regression analysis to estimate odds ratios (ORs) for being seen by a surgeon and for undergoing surgery. Cox proportional hazards analyses were performed to estimate hazard ratios (HRs) for survival adjusted for medical, nonmedical, and treatment characteristics. Results The rate of surgery for black patients was half that of white patients (25% v 46%; OR, 0.38; P < .001), which was caused by both a lower rate of seeing a surgeon (70% v 78%; OR, 0.66; P < .001) and a lower rate of surgery once seen (35% v 59%; OR, 0.38; P < .001). These racial disparities were only partly explained by differences in patient and cancer characteristics, and not by nonmedical factors, such as socioeconomic status. The 2-year survival rate was lower for black patients (18% v 25%; HR, 1.18; P = .004), but this racial difference disappeared when corrected for treatment received (adjusted HR, 1.02; P = .80). Conclusion Underuse of potentially curative surgery is an important potential explanation for the poorer survival of black patients with locoregional esophageal cancer. Barriers to surgical evaluation and treatment need to be reduced, whether related to patient or healthcare system factors.
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Affiliation(s)
- Ewout W Steyerberg
- Department of Public Health, Erasmus MC, PO Box 1738, 3000 DR Rotterdam, the Netherlands.
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Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health 2005; 94:2084-90. [PMID: 15569958 PMCID: PMC1448596 DOI: 10.2105/ajph.94.12.2084] [Citation(s) in RCA: 614] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the association between patient race/ethnicity and patient-physician communication during medical visits. METHODS We used audiotape and questionnaire data collected in 1998 and 2002 to determine whether the quality of medical-visit communication differs among African American versus White patients. We analyzed data from 458 African American and White patients who visited 61 physicians in the Baltimore, Md-Washington, DC-Northern Virginia metropolitan area. Outcome measures that assessed the communication process, patient-centeredness, and emotional tone (affect) of the medical visit were derived from audiotapes coded by independent raters. RESULTS Physicians were 23% more verbally dominant and engaged in 33% less patient-centered communication with African American patients than with White patients. Furthermore, both African American patients and their physicians exhibited lower levels of positive affect than White patients and their physicians did. CONCLUSIONS Patient-physician communication during medical visits differs among African American versus White patients. Interventions that increase physicians' patient-centeredness and awareness of affective cues with African Americans patients and that activate African American patients to participate in their health care are important strategies for addressing racial/ethnic disparities in health care.
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Affiliation(s)
- Rachel L Johnson
- Epidemiology and Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2223, USA
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Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med 2004; 19:101-10. [PMID: 15009789 PMCID: PMC1492144 DOI: 10.1111/j.1525-1497.2004.30262.x] [Citation(s) in RCA: 292] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine: 1) whether racial and ethnic differences exist in patients' perceptions of primary care provider (PCP) and general health care system-related bias and cultural competence; and 2) whether these differences are explained by patient demographics, source of care, or patient-provider communication variables. DESIGN Cross-sectional telephone survey. SETTING The Commonwealth Fund 2001 Health Care Quality Survey. SUBJECTS A total of 6,299 white, African-American, Hispanic, and Asian adults. MEASUREMENTS AND MAIN RESULTS Interviews were conducted using random-digit dialing; oversampling respondents from communities with high racial/ethnic minority concentrations; and yielding a 54.3% response rate. Main outcomes address respondents' perceptions of their PCPs' and health care system-related bias and cultural competence; adjusted probabilities (Pr) are reported for each ethnic group. Most racial/ethnic differences in perceptions of PCP bias and cultural competence were explained by demographics, source of care, and patient-physician communication variables. In contrast, racial/ethnic differences in patient perceptions of health care system-wide bias and cultural competence persisted even after controlling for confounders: African Americans, Hispanics, and Asians remained more likely than whites (P <.001) to perceive that: 1) they would have received better medical care if they belonged to a different race/ethnic group (Pr 0.13, Pr 0.08, Pr 0.08, and Pr 0.01, respectively); and 2) medical staff judged them unfairly or treated them with disrespect based on race/ethnicity (Pr 0.06, Pr 0.04, Pr 0.06, and Pr 0.01, respectively) and how well they speak English (Pr 0.09, Pr 0.06, Pr 0.06, and Pr 0.03, respectively). CONCLUSION While demographics, source of care, and patient-physician communication explain most racial and ethnic differences in patient perceptions of PCP cultural competence, differences in perceptions of health care system-wide bias and cultural competence are not fully explained by such factors. Future research should include closer examination of the sources of cultural bias in the US medical system.
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Affiliation(s)
- Rachel L Johnson
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD 21205-2223, USA
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Abstract
It is estimated that only a small proportion of patients with surgically remediable intractable epilepsy receive surgical treatment. There are multiple reasons why this is the case. Patients with intractable epilepsy are sometimes severely disabled and disability can create barriers to getting recommended care. Patients with epilepsy are not well informed about their condition and the available treatments. The incidence of epilepsy is similar in minority populations, and surgically remediable epilepsy frequently presents in adolescence. Nevertheless, these vulnerable populations have specific barriers to receiving epilepsy care, which are often not addressed. In addition, despite scientific evidence for the benefits of the surgical treatment of epilepsy, many healthcare providers do not recommend or adequately discuss surgery with patients. Solutions to these barriers will require interventions that result in informed and capable patients who actively participate in their care and healthcare providers who practice culturally sensitive, recommended care.
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Affiliation(s)
- Kari Swarztrauber
- Department of Neurology, Oregon Health Sciences University, and Health Services Research, Parkinson's Disease Research Education and Clinical Center, Portland Veterans Affairs Medical Center, Portland, Oregon, USA.
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Heisler M, Smith DM, Hayward RA, Krein SL, Kerr EA. Racial Disparities in Diabetes Care Processes, Outcomes, and Treatment Intensity. Med Care 2003; 41:1221-32. [PMID: 14583685 DOI: 10.1097/01.mlr.0000093421.64618.9c] [Citation(s) in RCA: 161] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Black Americans with diabetes have a higher burden of illness and mortality than do white Americans. However, the extent to which differences in medical care processes and treatment intensity contribute to poorer diabetes outcomes is unknown. OBJECTIVE To assess racial disparities in the quality of diabetes care processes, intermediate outcomes, and treatment intensity. METHODS We conducted an observational study of 801 white and 115 black patients who completed the Diabetes Quality Improvement Project survey (response rate=72%) in 21 Veterans Affairs (VA) facilities using survey data; medical record information on receipt of diabetes services (A1c, low-density lipoprotein [LDL], nephropathy screen, and foot and dilated eye examinations), and intermediate outcomes (glucose control measured by A1c; cholesterol control measured by LDL; and achieved level of blood pressure); and pharmacy data on filled prescriptions. RESULTS There were no racial differences in receipt of an A1c test or foot examination. Blacks were less likely than whites to have LDL checked in the past 2 years (72% vs. 80%, P<0.05) and to have a dilated eye examination (50% vs. 63%, P<0.01). Even after adjusting for patients' age, education, income, insulin use, diabetes self-management, duration, severity, comorbidities, and health services utilization, racial disparities in receipt of an LDL test and eye examination persisted. After taking into account the nested structure of the data using a random intercepts model, blacks remained significantly less likely to have LDL testing than whites who received care within the same facility (68% vs. 83%, P<0.01). In contrast, there were no longer differences in receipt of eye examinations, suggesting that black patients were more likely to be receiving care at facilities with overall lower rates of eye examinations. After adjusting for patient characteristics and facility effects, black patients were substantially more likely than whites to have poor cholesterol control (LDL > or =130) and blood pressure control (BP > or =140/90 mm Hg) (P<0.01). Among those with poor blood pressure and lipid control, blacks received as intensive treatment as whites for these conditions. CONCLUSIONS We found racial disparities in some diabetes care process and intermediate outcome quality measures, but not in intensity of treatment for those patients with poor control. Disparities in receipt of eye examinations were the result of black patients being more likely to receive care at lower-performing facilities, whereas for other quality measures, racial disparities within facilities were substantial.
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Affiliation(s)
- Michele Heisler
- Veterans Affairs Center for Practice Management & Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan 48113-0170, USA.
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Piette JD, Schillinger D, Potter MB, Heisler M. Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population. J Gen Intern Med 2003; 18:624-33. [PMID: 12911644 PMCID: PMC1494904 DOI: 10.1046/j.1525-1497.2003.31968.x] [Citation(s) in RCA: 174] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patient-provider communication is essential for effective care of diabetes and other chronic illnesses. However, the relative impact of general versus disease-specific communication on self-management is poorly understood, as are the determinants of these 2 communication dimensions. DESIGN Cross-sectional survey. SETTING Three VA heath care systems, 1 county health care system, and 1 university-based health care system. PATIENTS Seven hundred fifty-two diabetes patients were enrolled. Fifty-two percent were nonwhite, 18% had less than a high-school education, and 8% were primarily Spanish-speaking. MEASUREMENTS AND MAIN RESULTS Patients' assessments of providers' general and diabetes-specific communication were measured using validated scales. Self-reported foot care; and adherence to hypoglycemic medications, dietary recommendations, and exercise were measured using standard items. General and diabetes-specific communication reports were only moderately correlated (r =.35) and had differing predictors. In multivariate probit analyses, both dimensions of communication were independently associated with self-care in each of the 4 areas examined. Sociodemographically vulnerable patients (racial and language minorities and those with less education) reported communication that was as good or better than that reported by other patients. Patients receiving most of their diabetes care from their primary provider and patients with a longer primary care relationship reported better general communication. VA and county clinic patients reported better diabetes-specific communication than did university clinic patients. CONCLUSIONS General and diabetes-specific communication are related but unique facets of patient-provider interactions, and improving either one may improve self-management. Providers in these sites are communicating successfully with vulnerable patients. These findings reinforce the potential importance of continuity and differences among VA, county, and university health care systems as determinants of patient-provider communication.
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Affiliation(s)
- John D Piette
- Center for Practice Management and Outcomes Research, VA Ann Arbor Health Care System, Ann Arbor, Mich 48113-0170, USA.
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Volk RJ, Spann SJ, Cass AR, Hawley ST. Patient education for informed decision making about prostate cancer screening: a randomized controlled trial with 1-year follow-up. Ann Fam Med 2003; 1:22-8. [PMID: 15043176 PMCID: PMC1466553 DOI: 10.1370/afm.7] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The efficacy of prostate cancer screening is uncertain, and professional organizations recommend educating patients about potential harms and benefits. We evaluated the effect of a videotape decision aid on promoting informed decision making about prostate cancer screening among primary care patients. METHODS A group of 160 men, 45 to 70 years of age, with no history of prostate cancer, were randomized to view or not to view a 20-minute educational videotape before a routine office visit at a university-based family medicine clinic. The subjects were contacted again 1 year after their visit to assess their receipt of prostate cancer screening (digital rectal examination [DRE] or prostate-specific antigen [PSA] testing), their satisfaction with their screening decision, and knowledge retention since the baseline assessment. RESULTS Follow-up assessments were completed for 87.5% of the intervention subjects and 83.8% of the control subjects. The rate of DRE did not differ between the 2 groups. Prostate-specific antigen testing was reported by 24 of 70 (34.3%) intervention subjects and 37 of 67 (55.2%) control subjects (P = .01). African American men were more likely to have had PSA testing (9 of 16, 56.3%) than were white men (13 of 46, 28.3%) (P = .044). Satisfaction with the screening decision did not differ between the study groups. Intervention subjects were more knowledgeable of prostate cancer screening than were control subjects, although these differences declined within 1 year (P < .001). CONCLUSIONS Decision aids for prostate cancer screening can have a long-term effect on screening behavior and appear to promote informed decision making.
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Affiliation(s)
- Robert J Volk
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Tex 77098-3915, USA.
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Abstract
OBJECTIVE The goals of this study were to understand patient attitudes about the treatment of medically intractable epilepsy and to document potential barriers limiting patient access to the surgical treatment of epilepsy, highlighting the attitudes of adolescents and minorities. METHODS Focus groups of adults with intractable epilepsy (n=10), adolescents with intractable epilepsy (n=4), parents of adolescents with intractable epilepsy (n=4), and African-Americans with intractable epilepsy (n=6) were conducted at UCLA, Los Angeles, California. RESULTS Patients with intractable epilepsy communicated frustration with their continued disability despite trials of new medications. Their perceptions of the risks of the surgical treatment of epilepsy were exaggerated. Patients felt that their health care providers did not provide adequate information about epilepsy and portrayed epilepsy surgery negatively. CONCLUSIONS This study illuminated several factors that could change patient attitudes and help improve patient access to the surgical treatment of epilepsy, especially among minorities and adolescents.
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