The influence of physician race, age, and gender on physician attitudes toward advance care directives and preferences for end-of-life decision-making.

OBJECTIVE: To determine whether physicians' preferences for end-of-life decision-making differ between blacks and whites in the same pattern as patient preferences, with blacks being more likely than whites to prefer life-prolonging treatments. DESIGN: A mailed survey. SETTING AND PARTICIPANTS: American Medical Association (AMA) and National Medical Association (NMA) databases. To enrich the sample of black physicians, we targeted physicians in the AMA database practicing in high minority area zip codes and graduates of the traditionally black medical schools. MAIN OUTCOME MEASURES: Self-reported physician attitudes toward end-of-life decision-making and preference of treatment for themselves in persistent vegetative state or organic brain disease compared by race, controlling for age and gender. RESULTS: The 502 physicians (28%) who returned the questionnaire included 280 white and 157 black physicians. With regard to attitudes toward patient care, 58% of white physicians agreed that tube-feeding in terminally ill patients is "heroic," but only 28 % of black physicians agreed with the statement (P < .001). White physicians were more likely than black physicians to find physician-assisted suicide an acceptable treatment alternative (36.6% vs 26.5% of black physicians) (P < .05). With regard to the physicians preferences for future treatment of themselves for the persistent vegetative state scenario, black physicians were more than six times more likely than white physicians to request aggressive treatments (cardiopulmonary resuscitation, mechanical ventilation, or artificial feeding) for themselves (15.4% vs 2.5%) (P < .001). White physicians were almost three times as likely to want physician-assisted suicide (29.3% vs 11.8%) (P < .001) in this scenario. For a state of brain damage with no terminal illness, the majority of all physicians did not want aggressive treatment, but black physicians were nearly five times more likely than white physicians (23.0% vs 5.0%) (P < .001) to request these treatments. White physicians, on the other hand, were more than twice as likely to request physician-assisted suicide (22.5% vs 9.9%), P < .001 in this scenario. CONCLUSIONS: Physicians preferences for end-of-life treatment follow the same pattern by race as patient preferences, making it unlikely that low socioeconomic status or lack of familiarity with treatments account for the difference. Self-denoted race may be a surrogate marker for other, as yet undefined, factors. The full spectrum of treatment preferences should be considered in development of guidelines for end-of-life treatment in our diverse society.     

End-of-life health care planning among young-old adults: an assessment of psychosocial influences

OBJECTIVES: End-of-life planning among healthy older adults may protect them from unwanted medical treatments in later life, in the event that they become incapable of making health care decisions for themselves. We explore two formal and one informal components of end-of-life planning (living will, durable power of attorney for health care, and discussions) and assess whether one's health and health care encounters, personal beliefs, and experience with others' deaths affect these practices. METHODS: Using two waves of data (1992-1993 and 2004) from the Wisconsin Longitudinal Study, we estimated binary and multinomial logistic regression models to predict end-of-life preparations among a sample of community-dwelling persons aged 64-65 (N=3,838). RESULTS: Recent hospitalizations, personal beliefs (Death Avoidance and the belief that doctors should control health care decisions), and recent experience with the painful death of a loved one all influence end-of-life preparations. Consistent with past studies, we also found that education, gender, marital status, and religious affiliation affect end-of-life planning. DISCUSSION: Health care providers may encourage end-of-life preparations by assuaging patients' death anxiety and fostering decision-making autonomy. Initiating discussions about recent deaths of loved ones may be an effective way to trigger patients' own end-of-life preparations.     

End-of-life care in black and white: race matters for medical care of dying patients and their families

OBJECTIVES: To compare the end-of-life medical care experienced by African-American and white decedents and their families. DESIGN: Cross-sectional, retrospective survey with weighted results based on a two-stage probability sampling design. SETTING: Hospitals, nursing homes, and home-based medical services across the United States. PARTICIPANTS: Surrogates (N=1,447; primarily family members) for decedents from 22 states. MEASUREMENTS: Validated end-of-life care outcomes concerning symptom management, decision-making, informing and supporting families, individualized care, coordination, service utilization, and financial impact. RESULTS: Family members of African-American decedents were less likely than those of white decedents to rate the care received as excellent or very good (odds ratio (OR)=0.4). They were more likely to report absent (OR=2.4) or problematic (OR=1.9) physician communication, concerns with being informed (OR=2.5), and concerns with family support (OR=2.6). Family members of African Americans were less likely than those of whites to report that the decedent had treatment wishes (OR=0.3) or written advance care planning documents (OR=0.4). These differences persist when limiting the sample to respondents whose expectations for life-sustaining treatments matched treatments received. Family members of African-American decedents also were more likely to report financial hardship due to savings depletion (OR=2.1) or difficulty paying for care (OR=2.0) and that family/friends (OR=2.0) or home health workers (OR=1.9) provided home care. CONCLUSION: This national study brings evidence that racial disparities persist into end-of-life care, particularly regarding communication and family needs. Results also suggest different home care patterns and levels of financial impact.     

Hospice usage by minorities in the last year of life: results from the National Mortality Followback Survey

OBJECTIVES: To examine racial/ethnic variations in rates of hospice use in a national cohort and to identify individual characteristics associated with hospice use. DESIGN: Secondary analysis of the 1993 National Mortality Followback Survey (NMFS), a nationally obtained sample using death certificates and interviews with relatives (proxy respondents) to provide mortality, social, and economic data and information about healthcare utilization in the last year of life for 23,000 deceased individuals. SETTING: Hospice care. PARTICIPANTS: Individuals aged 15 and older who died in 1993. Subjects were included in this analysis if they died of nontraumatic causes (N = 11,291). MEASUREMENTS: Hospice use was dichotomized by proxy responses indicating use or nonuse of home or inpatient hospice services. The percentage of individuals using hospice services in the last year of life was calculated. RESULTS: Unadjusted bivariate results found that African Americans were less likely to use hospice than whites (odds ratio (OR) = 0.59; P <.001) and that those without a living will (LW) (OR = 0.23; P <.001) and without a cancer diagnosis (OR = 0.28; P <.001) were less likely to use hospice. The negative relationship between African Americans and hospice use was unaffected when controlled for sex, education, marital status, existence of a LW, income, and access to health care. Logistic models revealed that presence of a LW diminished the negative relationship between African Americans and hospice use, but the latter remained significant (OR = 0.83; P =.033). A subanalysis of subjects aged 55 and older showed a significant interaction between access to care and race/ethnicity with respect to hospice use (P =.044). Inclusion of income in this multivariable logistic model attenuated the relationship between African-American race/ethnicity and hospice use (OR = 0.77), and the difference between whites and African Americans became only marginally statistically significant (P =.060). CONCLUSION: In the 1993 NMFS, hospice use was negatively associated with African-American race/ethnicity independent of income and access to healthcare. The relationship is not independent of age, insurance type, or history of stroke. For subjects aged 55 and older, access to healthcare may be an important confounder of the negative relationship between African-American race/ethnicity and hospice use. Consistent with previous studies, this analysis found that African Americans were less likely to use LWs than whites. The reduced importance of African-American race/ethnicity on hospice use with the inclusion of presence of a LW in logistic models suggests that similar cultural processes may shape differences between African Americans and whites in advance care planning and hospice use.     

Beyond autonomy: diversifying end-of-life decision-making approaches to serve patients and families

Efforts to improve end-of-life decision-making quality have emphasized the principle of individual autonomy to better ensure that patients receive care consistent with their preferences. This principle has primarily been defined through court decisions during the past 3 decades as a patient's right to refuse medical technologies and avoid life-prolonging treatments. However, autonomy as traditionally defined only serves a small segment of dying patients. Patients might not value autonomy or consider autonomy important but define it differently than decision-making self-determination. Some patients also think in terms of their care goals rather than individual treatment preferences. Patients' functional and cognitive abilities, age, racial and ethnic backgrounds, and desire to avoid burdening loved ones may influence attitudes and definitions regarding autonomy. To improve end-of-life decision-making for an increasingly multicultural and aging population, the following priorities should be set: (1) Increase the flexibility of advance care planning and decision-making strategies used with capable patients to encompass diverse perceptions of autonomy; and (2) Improve communication between physicians and patients' families when patients lack decision-making capacity to facilitate decision-making and address families' emotional burdens. The goal of these priorities is to promote understanding of patients' and families' decision-making preferences and goals and to minimize decision-making burdens on families.     

Dialysis patients' preferences for family-based advance care planning.

BACKGROUND: Most patients do not participate in advance care planning with physicians. OBJECTIVE: To examine patients' preferences for involving their physicians and families in advance care planning. DESIGN: Face-to-face interviews with randomly selected patients. SETTING: Community-based dialysis units in one rural and one urban region. PARTICIPANTS: 400 hemodialysis patients. MEASUREMENTS: Questions about whom patients involve in advance care planning, whom patients would like to include in this planning, and patients' reactions to state legislation on surrogate decision makers in end-of-life care. RESULTS: Patients more frequently discussed preferences for end-of-life care with family members than with physicians (50% compared with 6%; P < 0.001). More patients wanted to include family members in future discussions of advance care planning than wanted to include physicians (91% compared with 36%; P < 0.001). Patients were most comfortable with legislation that granted their family end-of-life decision-making authority in the event of their own incapacity (P < 0.001). CONCLUSION: Most patients want to include their families more than their physicians in advance care planning.     

Racial/ethnic preferences, sex preferences, and perceived discrimination related to end-of-life care

This study investigated racial/ethnic preferences, sex preferences, and perceived discrimination related to end-of-life care. Ten focus groups and a follow-up survey were conducted to obtain in-depth information on end-of-life preferences across five racial/ethnic groups in Michigan stratified by sex. There were 73 focus group participants, including Arab Muslims, Arab Christians, Hispanics, blacks, and whites. The mean age+/-standard deviation was 67+/-8.5 (range 50-83). A focus group screener was used to recruit participants. A moderator discussion guide was used to guide the focus groups. A take-home questionnaire asked about demographic information and end-of-life issues. Arab Americans were in favor of making peace on earth and were against assisted suicide, extending life artificially, nursing homes, and telling the patient "bad news." Hispanic and black women were against assisted suicide and in favor of extending life, whereas the men in these groups felt the opposite. Hispanic women spoke of not wanting a feeding tube and would consider alternative medicine. Blacks were least opposed to nursing homes. For whites, it was important to have choices. When asked about discrimination related to end-of-life care, Muslim women spoke of cultural barriers, blacks spoke of inequities in the past, and whites spoke of age discrimination and abandonment when dying. As the population becomes more diverse and continues to age, it will be important to provide culturally and sex-sensitive end-of-life interventions to increase patient/family satisfaction and allocate resources appropriately.     

The quality of patient-doctor communication about end-of-life care: a study of patients with advanced AIDS and their primary care clinicians.

OBJECTIVE: To assess prevalence and quality of end-of-life communication between persons with advanced AIDS and their clinicians and to identify patient and clinician characteristics associated with this communication. DESIGN: Prospective cohort study of 57 patients with AIDS and their primary care clinicians. SETTING: University-based and private clinics in Seattle, Washington. PATIENTS: Patients had a prior AIDS-defining illness and a CD4 cell count of less than 100 x 10(6) cells/l. MAIN OUTCOME MEASURES: Quality of patient-clinician communication about end-of-life care, validated against patient satisfaction and patient-clinician concordance on advance directives and treatment preferences. RESULTS: Patients reported they had communication about end-of-life care with their clinician in 31 of 57 cases (54%) while clinicians reported they had this discussion in 36 of 57 cases (64%). Patients and clinicians gave concordant answers in 42 patient-clinician pairs. In 15 pairs (26%), patients and clinicians disagreed about whether end-of-life communication had occurred. African-American and Hispanic patients were less likely to report having communication than non-Hispanic white patients (chi-square analysis: chi2 = 4.67; P < 0.05); injection drug users and women with high-risk sexual partners were less likely to report communication than homosexual or bisexual men (chi2 = 4.67; P < 0.05). A four-item measure of patients' assessment of the quality of communication about end-of-life care had good internal consistency (Cronbach's alpha 0.81) and was significantly correlated with overall satisfaction with medical care (r2 = 0.76; P < 0.0001). Patients with lower income reported lower quality of communication (chi2 = 5.82; P = 0.05). If patients assessed quality of communication as high, their clinicians were more likely to know if the patient had a durable power of attorney for health care (chi2 = 4.95; P = 0.03) but were not more likely to predict patients' preferences for life-sustaining treatments. CONCLUSIONS: Quality of patient-clinician communication about end-of-life care can be measured in a brief questionnaire; higher quality of this communication is associated with higher satisfaction with care and increased clinician knowledge of patients' advance directives. Since socioeconomic status and ethnicity are associated with both the occurrence and quality of this communication, future interventions in end-of-life care should assess the effect of these variables. Given the important and independent goals of improving patient-clinician communication about end-of-life care and improving the quality of care at the end of life, future studies should test interventions to improve the quality of communication and determine whether improving this communication improves the quality of care at the end of life.     

Advance care planning and health care preferences of community-dwelling elders: the Framingham Heart Study

OBJECTIVE: The study objective was to describe self-reported advance care planning, health care preferences, use of advance directives, and health perceptions in a very elderly community-dwelling sample. METHODS: We interviewed surviving participants of the original cohort of the Framingham Heart Study who were cognitively intact and attended a routine research examination between February 2004 and October 2005. Participants were queried about discussions about end-of-life care, preferences for care, documentation of advance directives, and health perceptions. RESULTS: Among 220 community-dwelling respondents, 67% were women with a mean age of 88 years (range 84-100 years). Overall, 69% discussed their wishes for medical care at the end of life with someone, but only 17% discussed their wishes with a physician or health care provider. Two thirds had a health care proxy, 55% had a living will, and 41% had both. Most (80%) respondents preferred comfort care over life-extending care, and 71% preferred to die at home; however, substantially fewer respondents said they would rather die than receive specific life-prolonging interventions (chronic ventilator [63%] or feeding tube [64%]). Many were willing to endure distressing health states, with fewer than half indicating that they would rather die than live out their life in a great deal of pain (46%) or be confused and/or forgetful (45%) all of the time. CONCLUSIONS: Although the vast majority of very elderly community-dwellers in this sample appear to prefer comfort measures at the end of life, many said they were willing to endure specific life-prolonging interventions and distressing health states to avoid death. Our results highlight the need for physicians to better understand patients' preferences and goals of care to help them make informed decisions at the end of life.     

The influence of religious beliefs and practices on health care decision-making among HIV positive adolescents

ABSTRACT

It is unknown if religiousness/spirituality influences end-of-life treatment preferences among adolescents. Investigators assessed whether religiousness/spirituality moderates the relationship between an advance care planning intervention and end-of-life treatment preferences among 85 primarily African-American adolescents living with HIV/AIDS in outpatient-hospital-based HIV-specialty clinics in the United States. Adolescents aged 14–21 years living with HIV/AIDS and their families were randomized to three-weekly-60-minute sessions either: advance care planning (survey, goals of care conversation, advance directive); or control (developmental history, safety tips, nutrition/exercise). At 3-months post-intervention the intervention effect (decreasing the likelihood of choosing to continue treatments in all situations) was significantly moderated by religiousness/spirituality. Highly religious/spiritual adolescents were four times more likely to choose to continue treatments in all situations. Thus, intensive treatments at end-of-life may represent health equity, rather than health disparity. The belief believed that HIV is a punishment from God at baseline (15%, 14/94) was not associated with end-of-life treatment preferences. Twelve percent (11/94) reported they had stopped taking HIV medications for more than 3 days because of the belief in a miracle. Religiousness moderates adolescent’s medical decision-making. Adolescents who believe in miracles should receive chaplaincy referrals to help maintain medication adherence.     

High rates of advance care planning in New York City's elderly population

BACKGROUND: Previous studies have demonstrated low rates of advance care planning (ACP), particularly among nonwhite populations, raising questions about the generalizability of this decision-making process. OBJECTIVE: To explore factors that may influence patients' willingness to engage in ACP. DESIGN: Survey. SETTING: Thirty-four randomly selected New York City senior centers. PARTICIPANTS: A total of 700 African American (n = 239), Hispanic (n = 237), and white (n = 224) adults 60 years and older. INTERVENTION: Participants were administered a 51-item survey that assessed attitudes, beliefs, and practices regarding ACP. MAIN OUTCOME MEASURES: Attitudes and beliefs about physicians' trustworthiness, fatalism, beliefs about surrogate decision making, and comfort discussing end-of-life medical care; factors associated with health care proxy completion; and health care proxy completion rates. RESULTS: More than one third of the participants had completed a health care proxy. There were no significant differences in completion rates across the 3 ethnic groups. Respondents who had a primary care physician (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3-3.2), were more knowledgeable about advance directives (OR, 2.0; 95% CI, 1.4-2.9), or had seen a friend or family member use a mechanical ventilator (OR, 1.5; 95% CI, 1.02-2.1) were significantly more likely to have designated a health care proxy. Respondents who were only comfortable discussing ACP if the discussion was initiated by the physician (OR, 0.6; 95% CI, 0.0-0.8) were significantly less likely to have completed a health care proxy. CONCLUSIONS: African American, Hispanic, and white community-dwelling, older adults had similarly high rates of advance directive completion. The primary predictors of advance directive completion involved modifiable factors such as established primary care physicians, personal experience with mechanical ventilation, knowledge about the process of ACP, and physicians' willingness to effectively initiate such discussions. Some of the racial/ethnic differences in desire for collective family-based decision making that were observed in this study have implications for the evolution of ACP policy that respects and operationalizes these preferences.     

Life‐Sustaining Treatments: What Do Physicians Want and Do They Express Their Wishes to Others?

OBJECTIVES: To assess whether older physicians have discussed their preferences for medical care at the end of life with their physicians, whether they have established an advance directive, and what life-sustaining treatment they wish in the event of incapacity to make these decisions for themselves. DESIGN: Mailed survey to a cohort of physicians. SETTING: Physicians who were medical students at the Johns Hopkins University in graduating classes from 1946 to 1964. PARTICIPANTS: Physicians who completed the advance directive questionnaire (mean age 68). MEASUREMENTS: Questionnaires were sent out to known surviving physicians of the Precursors Study, an on-going study that began in 1946, asking physicians about their preferences for life-sustaining treatments. RESULTS: Of 999 physicians who were sent the survey, 765 (77%) responded. Forty-six percent of the physicians felt that their own doctors were unaware of their treatment preferences or were not sure, and of these respondents, 59% had no intention of discussing their wishes with their doctors within the next year. In contrast, 89% thought their families were probably or definitely aware of their preferences. Sixty-four percent reported that they had established an advance directive. Compared with physicians without advance directives, physicians who established an advance directive were more likely to believe that their doctors (odds ratio (OR) = 3.42, 95% confidence interval (CI) = 2.49-4.69) or family members (OR = 9.58, 95% CI = 5.33-17.23) were aware of their preferences for end-of-life care and were more likely to refuse treatments than those without advance directives. CONCLUSION: This survey of physicians calls attention to the gap between preferences for medical care at the end of life and expressing wishes to others through discussion and advance directives, even among physicians.     

Current research findings on end-of-life decision making among racially or ethnically diverse groups

PURPOSE: We reviewed the research literature on racial or ethnic diversity and end-of-life decision making in order to identify key findings and provide recommendations for future research. DESIGN AND METHODS: We identified 33 empirical studies in which race or ethnicity was investigated as either a variable predicting treatment preferences or choices, where racial or ethnic groups were compared in their end-of-life decisions, or where the end-of-life decision making of a single minority group was studied in depth. We conducted a narrative review and identified four topical domains of study: advance directives; life support; disclosure and communication of diagnosis, prognosis, and preferences; and designation of primary decision makers. RESULTS: Non-White racial or ethnic groups generally lacked knowledge of advance directives and were less likely than Whites to support advance directives. African Americans were consistently found to prefer the use of life support; Asians and Hispanics were more likely to prefer family-centered decision making than other racial or ethnic groups. Variations within groups existed and were related to cultural values, demographic characteristics, level of acculturation, and knowledge of end-of-life treatment options. Common methodological limitations of these studies were lack of theoretical framework, use of cross-sectional designs, convenience samples, and self-developed measurement scales. IMPLICATIONS: Although the studies are limited by methodological concerns, identified differences in end-of-life decision-making preference and practice suggest that clinical care and policy should recognize the variety of values and preferences found among diverse racial or ethnic groups. Future research priorities are described to better inform clinicians and policy makers about ways to allow for more culturally sensitive approaches to end-of-life care.     

Asian Americans’ reports of their health care experiences

OBJECTIVE: To examine how Asian race/ethnicity affects patients' health care experiences and satisfaction with care. DESIGN: Telephone interview using random-digit dialing, stratified to over-sample adults living in areas with disproportionately large numbers of minorities. PARTICIPANTS AND SETTING: White (N = 3,205) and Asian-American (N = 521) respondents, weighted to represent all such adults living in the continental U.S. in telephone households. MEASUREMENTS: Reports of health care experiences and trust in the doctor at the last visit, and overall satisfaction with care and desire to change doctors in the last 2 years. MAIN RESULTS: Asian Americans were less likely than whites to report that their doctors ever talked to them about lifestyle or mental health issues (P < or =.01). They were more likely to report that their regular doctors did not understand their background and values (P < or =.01). When asked about the last visit, they were more likely to report that their doctors did not listen, spend as much time, or involve them in decisions about care as much as they wanted (all P < or =.0001). In multivariable analyses, Asian Americans were less likely than whites to report that they were very satisfied with care (odds ratio [OR], 0.64, 95% confidence interval [CI], 0.42 to 0.99). However, they were not significantly less likely than whites to trust their doctors (OR, 0.79, 95% CI, 0.52 to 1.20), or to change doctors (OR, 0.93, 95% CI, 0.56 to 1.56). CONCLUSIONS: In a national survey, Asian Americans were less likely to receive counseling and less likely to report positive interactions with their doctors than white respondents. More research is needed to determine the reasons for these differences.     

Hepatitis C risk assessment, testing and referral for treatment in urban primary care： Role of race and ethnicity

AIMTo determine rates of hepatitis C(HCV)risk factor ascertainment,testing,and referral in urban primary care practices,with particular attention to the effect of race and ethnicity.METHODSRetrospective chart review from four primary care sites in Philadelphia;two academic primary care practices and two community clinics was performed.Demographics,HCV risk factors,and other risk exposure information were collected.RESULTSFour thousand four hundred and seven charts were reviewed.Providers documented histories of injection drug use(IDU)and transfusion for less than 20% and 5% of patients,respectively.Only 55% of patients who admitted IDU were tested for HCV.Overall,minorities were more likely to have information regarding a risk factor documented than their white counterparts (79% vs 68%,P ＜ 0.0001).Hispanics were less likely to have a risk factor history documented,compared to blacks and whites(P ＜ 0.0001).Overall,minorities were less likely to be tested for HCV than whites in the presence of a known risk factor(23% vs 35%,P = 0.004).Among patients without documentation of risk factors,blacks and Hispanics were more likely to be tested than whites(20% and 24%,vs 13%,P ＜ 0.005,respectively).CONCLUSION(1)Documentation of an HCV risk factor history in urban primary care is uncommon,(2)Racial differences exist with respect to HCV risk factor ascertainment and testing,(3)Minority patients,positive for HCV,are less likely to be referred for subspecialty care and treatment.Overall,minorities are less likely to be tested for HCV than whites in the presence of a known risk factor.     

Advance care planning in nursing homes: correlates of capacity and possession of advance directives

PURPOSE: The identification of nursing home residents who can continue to participate in advance care planning about end-of-life care is a critical clinical and bioethical issue. This study uses high quality observational research to identify correlates of advance care planning in nursing homes, including objective measurement of capacity. DESIGN AND METHODS: The authors used cross-sectional, cohort study between 1997 and 1999. Seventy-eight residents (M age = 83.97, SD = 8.2) and their proxies (M age = 59.23, SD = 11.77) were included across five nursing homes. The authors obtained data via chart review, proxy interviews, resident assessments, survey completion by certified nursing assistants, and direct observation of residents' daily behaviors. RESULTS: Capacity assessments revealed that most residents could state a simple treatment preference (82.4%), but a sizable number did not retain capacity to understand treatment alternatives or appreciate the consequences of their choice. Global cognitive ability (Mini-Mental State Examination score) was related to understanding and appreciation. When the authors removed the effects of global cognitive ability, understanding and appreciation were related to time spent by residents in verbal interaction with others. Residents were more likely to possess advance directives when proxies possessed advance directives, proxies were less religious, and residents were socially engaged. IMPLICATIONS: Assessment of proxy beliefs and direct determination of residents' decisional capacity and social engagement may help nursing home staff identify families who may participate in advance planning for end-of-life medical care. Measures of global cognitive ability offer limited information about resident capacity for decision making. Decisional capacity assessments should enhance the verbal ability of individuals with dementia by reducing reliance on memory in the assessment process. Interventions to engage residents and families in structured discussions for end-of-life planning are needed.     

Race/ethnic disparities in HIV testing and knowledge about treatment for HIV/AIDS: United States, 2001

In the United States, access to HIV care has remained suboptimal for people of color. To assess racial disparities in HIV testing and knowledge about treatment for HIV/AIDS in the United States, we analyzed the 2001 Behavioral Risk Factor Surveillance System. We obtained the percentage of respondents aged 18 to 64 years who: (1) were tested for HIV ever and recently (in the past 12 months) excluding for blood donations and (2) responded "true" to the statement, "There are medical treatments available that are intended to help a person who is infected with HIV to live longer." We calculated the difference in rates of HIV testing and knowledge about treatment between blacks or Latinos compared to whites. Overall, of the 162,962 respondents, 44.7% had been tested for HIV and 12.8% were tested in the past year. Overall, 86.4% answered "true" to the statement on treatment for HIV/AIDS. HIV testing rates were significantly lower among whites (ever, 42.4%; recent, 10.8%) than blacks (ever, 59.7%; recent, 23.4%) or Latinos (ever 45.6%, recent 14.8%). Compared to knowledge among whites (89.6%), knowledge level was, lower among blacks (odds ratio [OR] = 0.58, 95% confidence interval [CI] = 0.52, 0.64) and Latinos (OR = 0.67, 95%CI = 0.59, 0.75) even after adjusting for sociodemographics and HIV testing status. The knowledge gap among blacks compared to whites decreased with increasing income and education. We conclude that knowledge about the availability of antiretroviral treatment was high overall. Compared to whites, blacks, and latinos had significantly higher HIV testing rates but significantly lower knowledge about antiretrovirals.     

Racial differences in trust in health care providers

BACKGROUND: Although trust in health care providers (physicians, nurses, and others) may be lower among African Americans compared with whites, limited information is available on factors that are associated with low trust in these populations. This study evaluated the association between trust in health care providers and prior health care experiences, structural characteristics of health care, and sociodemographic factors among African Americans and whites. METHODS: National survey of 954 non-Hispanic adult African Americans (n = 432) and whites (n = 522). RESULTS: African Americans (44.7%) were more likely than whites (33.5%) to report low levels of trust in health care providers (chi(2) = 12.40, P<.001). Fewer quality interactions with health care providers had a significant effect on low trust among African Americans (odds ratio [OR], 3.23; 95% confidence interval [CI], 1.97-5.29; P<.001) and whites (OR, 3.99; 95% CI, 2.44-6.50; P<.001). Among African Americans, respondents whose usual source of care was not a physician's office were most likely to report low trust (OR, 1.73; 95% CI, 1.15-2.61; P = .02), whereas among whites, women (OR, 1.54; 95% CI, 1.04-2.30; P = .03) and respondents with fewer annual health care visits (OR, 1.52; 95% CI, 1.02-2.28; P = .04) were most likely to report low trust. CONCLUSIONS: Compared with whites, African Americans were most likely to report low trust in health care providers. While fewer quality interactions with health care providers were associated significantly with low trust in both populations, usual source of medical care was only associated with low trust among African Americans, whereas sex and the number of annual health care visits were associated with low trust among whites. Different factors may influence trust in health care providers among African Americans and whites.     

Racial and ethnic differences in patients' preferences for initial care by specialists

PURPOSE: To examine racial and ethnic differences in patients' preferences for initial care by specialists, and to determine whether trust in the physician and health beliefs account for these differences. METHODS: We conducted a cross-sectional study of 646 patients in the waiting room of three academic-based internal medicine outpatient practices. We asked subjects about their preference to see their primary care provider or a specialist first regarding the actual health problem that had brought them to see their physician as well as regarding three hypothetical scenarios (2 weeks of new-onset exertional chest pain, 2 months of knee pain, and rash for 4 weeks). We examined the relation among patients' preference for initial care by a specialist and their demographic characteristics, global ratings of their primary care physician and health plan, trust in their primary care physician, and other health beliefs and attitudes. RESULTS: Averaged for the three scenarios and actual health problem, 13% of patients preferred to see a specialist first. Adjusting for all other covariates, blacks (risk ratio [RR] = 0.55; 95% confidence interval [CI]: 0.20 to 0.92) and Asians (RR = 0.46; 95% CI: 0.19 to 0.75) were much less likely to prefer a specialist than were whites. Patients with less confidence in their primary care physician and greater certainty about needed tests and treatments were more likely to prefer a specialist. These variables, however, did not explain the difference in preference for specialist care among blacks, Asians, and whites. CONCLUSION: Blacks and Asians are less likely than whites to prefer initial care by a specialist. Future studies should examine whether differences in preference for care lead minorities to underutilize appropriate specialty care or lead whites to overuse specialty care.