Association Between Prior Experiences of Discrimination and Patients’ Attitudes Towards Health Care Providers Collecting Information About Race and Ethnicity

BACKGROUND  Previously, we reported a high level of comfort among Californians for collecting race/ethnicity information by health care providers (HCPs). However, minorities were less comfortable providing race/ethnicity information and were more worried than non-Hispanic whites about the potential misuse of this information. OBJECTIVE  To determine if perceived experiences of discrimination (both in general and in medical care) were associated with comfort providing race/ethnicity information, and conversely, to worry about providing the information. DESIGN AND PARTICIPANTS  Telephone survey of 480 Californians, including 101 whites, 98 Asians, 173 Hispanics, 82 blacks, and 26 multiracial individuals. MEASUREMENTS  Comfort level giving HCPs information about race/ethnicity (measured on a 1–10 scale, with text anchors of “very uncomfortable” at 1 and “very comfortable” at 10), worry that the information could be used to discriminate against patients, and worry that the information could be used to find undocumented immigrants. Worry was measured using a four-point Likert scale- not worried at all, a little worried, somewhat worried, and very worried. Respondents were also asked about perceived discrimination in general and perceived discrimination in medical care. RESULTS  Compared to whites, Hispanics (Beta-coefficient (BC) = -1.16, SE = 0.51) and Mandarin/Cantonese-speaking Asians (BC = -1.40, SE = 0.65) reported significantly less comfort giving HCPs information about their race/ethnicity, while blacks (BC = 0.70, SE = 0.16), Hispanics (BC = 0.91, SE = 0.18), and multiracial individuals (BC = 0.63, SE = 0.24) were significantly more worried that race/ethnicity information could be used to discriminate against them. Adjusting for perceived experiences of discrimination in general and in medical care partially explained the higher discomfort and worry among minorities. CONCLUSIONS  Perceived experiences of discrimination are associated with greater discomfort and worry about providing race/ethnicity data. Health care institutions should consider how they can address the public’s concerns about possible misuses of data.     

Early Initiation of Colorectal Cancer Screening in Individuals with Affected First-degree Relatives

Background Several guidelines recommend initiating colorectal cancer screening at age 40 for individuals with affected first-degree relatives, yet little evidence exists describing how often these individuals receive screening procedures. Objectives To determine the proportion of individuals in whom early initiation of colorectal cancer screening might be indicated and whether screening disparities exist. Design Population-based Supplemental Cancer Control Module to the 2000 National Health Interview Survey. Participants Respondents, 5,564, aged 40 to 49 years were included within the analysis. Measurements Patient self-report of sigmoidoscopy, colonoscopy, or fecal occult blood test. Results Overall, 279 respondents (5.4%: 95% C.I., 4.7, 6.2) reported having a first-degree relative affected with colorectal cancer. For individuals with a positive family history, 67 whites (27.9%: 95% C.I., 21.1, 34.5) and 3 African American (9.3%: 95% C.I., 1.7, 37.9) had undergone an endoscopic procedure within the previous 10 years (P-value = .03). After adjusting for age, family history, gender, educational level, insurance status, and usual source of care, whites were more likely to be current with early initiation endoscopic screening recommendations than African Americans (OR = 1.38: 95% C.I., 1.01, 1.87). Having an affected first-degree relative with colorectal cancer appeared to have a stronger impact on endoscopic screening for whites (OR = 3.21: 95% C.I., 2.31, 4.46) than for African Americans (OR = 1.05: 95% C.I., 0.15, 7.21). Conclusions White participants with a family history are more likely to have endoscopic procedures beginning before age 50 than African Americans.     

Differences in the Quality of the Patient–Physician Relationship Among Terminally Ill African-American and White Patients: Impact on Advance Care Planning and Treatment Preferences

BACKGROUND Little is known about the quality of the patient–physician relationship for terminally ill African Americans. OBJECTIVE To compare the quality of the patient–physician relationship between African-American and white patients and examine the extent to which relationship quality contributes to differences in advance care planning (ACP) and preferences for intensive life-sustaining treatment (LST). DESIGN Cross sectional survey of 803 terminally ill African-American and white patients. MEASUREMENTS Patient-reported quality of the patient–physician relationship (degree of trust, perceived respect, and joint decision making; skill in breaking bad news and listening; help in navigating the medical system), ACP, preferences for LST (cardiopulmonary resuscitation, major surgery, mechanical ventilation, and dialysis). RESULTS The quality of the patient–physician relationship was worse for African Americans than for white patients by all measures except trust. African Americans were less likely to have an ACP (adjusted relative risk [aRR] = 0.66, 95%CI = 0.52–0.84), and were more likely to have a preference for cardiopulmonary resuscitation and dialysis (aRR = 1.28, 95%CI = 1.03–1.58; aRR = 1.25, 95%CI = 1.07–1.47, respectively). Additional adjustment for the quality of the patient–physician relationship had no impact on the differences in ACP and treatment preferences. CONCLUSIONS Lower reported patient–physician relationship quality for African-American patients does not explain the observed differences between African Americans and whites in ACP and preferences for LST.     

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.     

Hypertensive Patients’ Race, Health Beliefs, Process of Care, and Medication Adherence

BACKGROUND African Americans have higher rates of hypertension and worse blood pressure (BP) control than Whites, and poorer medication adherence may contribute to this phenomenon. We explored associations among patients’ race, self-reported experiences with clinicians, attitudes and beliefs about hypertension, and ultimately, medication adherence, among a sample with no racial disparities in BP control, to determine what lessons we could learn from patients and providers in this setting. METHODS We recruited 793 White and African-American (58%) patients previously diagnosed with hypertension from 3 VA medical centers to participate in survey assessments of each of the above dimensions, subsequent to a primary care clinic visit. RESULTS African-American patients’ providers were significantly more active in advising and counseling about hypertension care and medication adherence. African-American patients indicated greater knowledge or heightened awareness of the importance of controlling their BP, but there were no race differences on a summary adherence measure. In multivariate models modeling medication adherence, race was not significant, but having been told to split one’s pills, believing one’s BP continues to be high, and having one’s provider discuss things to do to make it easier to take BP medications were each significantly associated with worse adherence, whereas having more confidence in one’s ability to take BP medications as prescribed was associated with better adherence (all p’s  ≤ .02). CONCLUSION When both physicians and patients take BP management seriously, disparities in BP adherence and control may be reduced.     

Perceived Discrimination in Health Care and Use of Preventive Health Services

Objective  To examine the relationship between perceived discrimination and preventive health care utilization. Design and Participants  Cross-sectional analysis using the 2004 Behavioral Risk Factor Surveillance System “Reactions to Race” module (N = 28,839). Measurements  Outcomes were self-reported utilization of seven preventive health services. Predictors included perceived negative and positive racial discrimination (vs. none) while seeking health care in the past year. Multivariable models adjusted for additional patient characteristics. Main Results  In unadjusted models, negative discrimination was significantly associated with less utilization of mammogram, pap test, PSA test, blood stool test, and sigmoidoscopy/colonoscopy (ORs = 0.53–0.73, p < .05), but not flu or pneumococcal vaccines (ORs = 0.76 and 0.84). Positive discrimination was significantly associated with more utilization of all services (ORs = 1.29–1.58, p < .05) except pap test (OR = 0.94). In adjusted models, neither negative nor positive discrimination was predictive of utilization, except for PSA test (positive discrimination OR = 1.33, p < .05). Conclusions  Perceived racial discrimination in health care does not independently predict preventive health care utilization.     

Investigating Racial Differences in Coping with Chronic Osteoarthritis Pain

Osteoarthritis is a prevalent disease in older patients of all racial groups, and it is known to cause significant pain and functional disability. Racial differences in how patients cope with the chronic pain of knee or hip osteoarthritis may have implications for utilization of treatment modalities such as joint replacement. Therefore, we examined the relationships between patient race and pain coping strategies (diverting attention, reinterpreting pain, catastrophizing, ignoring sensations, hoping and praying, coping self-statements, and increasing behavior activities) for hip and knee osteoarthritis. This is a cross-sectional survey of 939 veterans 50 to 79 years old with chronic hip or knee osteoarthritis pain recruited from VA primary care clinics in Philadelphia and Pittsburgh. Patients had to have moderate to severe hip or knee osteoarthritis symptoms as measured by the WOMAC index. Standard, validated instruments were used to obtain information on attitudes and use of prayer, pain coping strategies, and arthritis self-efficacy. Analysis included separate multivariable models adjusting for demographic and clinical characteristics. Attitudes on prayer differed, with African Americans being more likely to perceive prayer as helpful (adjusted OR = 3.38, 95% CI 2.35 to 4.86) and to have tried prayer (adjusted OR = 2.28, 95% 1.66 to 3.13) to manage their osteoarthritis pain. Upon evaluating the coping strategies, we found that, compared to whites, African Americans had greater use of the hoping and praying method (β = 0.74, 95% CI 0.50 to 0.99). Race was not associated with arthritis pain self-efficacy, arthritis function self-efficacy, or any other coping strategies. This increased use of the hoping and praying coping strategy by African Americans may play a role in the decreased utilization of total joint arthroplasty among African Americans compared to whites. Further investigation of the role this coping strategy has on the decision making process for total joint arthroplasty should be explored.     

Barriers to treatment adherence among African American and white women with systemic lupus erythematosus

OBJECTIVE: To determine whether African Americans with systemic lupus erythematosus (SLE) have poorer treatment adherence than whites, and to determine ethnic group differences in barriers to adherence, and how barriers affect adherence. METHODS: We compared 68 African American and 54 white women with SLE on 19 potential barriers, on 2 adherence behaviors during the past year, and on how the potential barriers relate to each nonadherence behavior. RESULTS: African Americans and whites were similar on most barriers, although African Americans were more likely to rely on religion and were more concerned about long-term medication effects. The 2 ethnic groups were comparable on medication nonadherence, but whites tended to have poorer clinic appointment adherence than African Americans. Finally, we found that barriers related to negative affect (depression, medication concerns, physical symptoms) as well as short-term memory problems and the need for child or elder care were associated with nonadherence among African Americans, whereas perceived treatment inefficacy and lacking trust in physicians were associated with nonadherence among whites. CONCLUSION: Relationships between adherence barriers and nonadherence may be ethnicity specific, suggesting that interventions to address barriers should be targeted to specific groups.     

Providing Patients Web-based Data to Inform Physician Choice: If You Build It,Will They Come?

Background Despite growing emphasis on public reporting of health care quality data, available data are often ignored. Objective To evaluate the usefulness of web-based physician-level data for patients choosing a new primary care physician (PCP). Design Patients seeking a new PCP (n = 2225) were invited to view web-based information including PCP credentials, personal characteristics, office location and hours, and patient experience scores. Patient experience scores included validated measures of interpersonal quality, appointment access, care coordination, health promotion, and patient recommendations of the PCP. After viewing the website, participants indicated their preferred PCP and completed a study questionnaire. Results Of the invited participants, 17% visited the website (n = 382). Patient experience scores were cited most frequently as important to physician choice (51%). Among these measures, patients’ highest priorities were interpersonal quality (37%) and patient recommendations of the PCP (41%). For patients citing these priorities, the odds of choosing a highly scored physician after viewing the data was nearly 10 times that of choosing such a physician by chance (odds ratio (OR) = 9.52 and 9.71, respectively). Conclusions Targeting patients known to be making a health care decision appears to promote the use of performance data. Patients particularly valued data concerning other patients’ experiences and, after viewing the data, made choices well-aligned with their priorities.     

Self care for chronic illness: Older African Americans and whites

In-person interviews with two hundred and twenty-one older African Americans and whites in Allegheny County, Pennsylvania on their use of self care activities in the care of one of four chronic illnesses (chronic obstructive pulmonary disease (COPD), heart disease, diabetes mellitus, and arthritis, addressed which types of self care they used for each of these illnesses) the similarities and differences between African Americans and whites in their use of self care and how self care is initiated, modified and integrated into a context that includes help from others. The most common response in each of the illnesses was the use of medications or medical treatments by both African Americans and whites. However, there were some differences in the self care practices used by these two groups by illness type. Whites reported monitoring their illness significantly more than African Americans for diabetes and using assistive devices in the management of COPD significantly more than African Americans. While both African Americans and whites practice self care similarly in the management of heart disease, African Americans reported greater use of exercise in their management of arthritis. The amount of assistance provided by others in support of self care varied by illness and by African American and white. The differences in self care usage may be attributed to many factors, among them, differences in cultural experiences with the illness, health beliefs regarding its efficacy and the amount of assistance received from informal supports.     

Acute coronary syndromes in black americans: Is treatment different? should it be?

Black Americans with acute coronary syndromes (ACS) are at greater risk and have poorer outcomes than white Americans. The reasons for this appears, at least in part, to be due to a greater burden of baseline risk factors, longer delays prior to seeking medical care, and underutilization of aggressive treatment strategies in high-risk individuals. A guiding principle of treatment of ACS is that patients at highest risk should receive the most immediate and aggressive therapy. However, compared with whites, blacks with ACS paradoxically receive less aggressive medical therapy, and are less often referred for cardiac catheterization, percutaneous coronary interventions, and bypass surgery. Treatment is—but should not be—different in black Americans. Changing this and improving care for ACS in blacks requires better strategies for decreasing patient delays, earlier recognition and diagnosis of ACS, and more effective implementation of evidence-based treatment guidelines.     

What is the Business Case for Improving Care for Patients with Complex Conditions?

Background Although hospice care can alleviate suffering at the end of life for patients with cancer, it remains underutilized, particularly by African Americans and Hispanics. Objective To examine whether the racial composition of the census tract where an individual resides is associated with hospice use. Design Retrospective analysis of the Surveillance, Epidemiology, and End Results–Medicare file for individuals dying from breast, colorectal, lung, or prostate cancer (n = 70,669). Measurements Hospice use during the 12 months before death. Results Hospice was most commonly used by individuals who lived in areas with fewer African-American and Hispanic residents (47%), and was least commonly used by individuals who lived in areas with a high percentage of African-American and Hispanic residents (35%). Hispanics (odds ratio 0.51, 95% confidence interval 0.29–0.91) and African Americans (0.56, 0.44–0.71) were less likely to use hospice if they lived in a census tract with a high percentage of both African Americans and Hispanics than if they lived in a low minority tract. African Americans and whites were less likely to receive hospice care if they lived in a census tract with a high percentage of Hispanics than if they lived in a low minority area. Conclusions Increasing hospice use may require interventions to improve the delivery of hospice care in minority communities.     

Exploring racial/ethnic disparities in hypertension care among patients served by health centers in the United States

Some racial/ethnic minorities are more likely to have hypertension and experience increased hypertension‐related morbidity and mortality compared to whites. Health Resources and Services Administration‐funded health centers care for over 27 million patients, 62 percent of whom are racial/ethnic minorities. We assessed the presence of racial/ethnic disparities in (a) hypertension management and (b) hypertension outcomes among health center patients. We used data from the 2014 Health Center Patient Survey and performed multilevel logistic regression models to predict hypertension management counseling, patient adherence to counseling and medication regimen, management plan receipt, high blood pressure at last clinical visit, confidence in hypertension self‐management, and hypertension‐related emergency department (ED) episodes or hospitalizations in the past year. We controlled for patient characteristics including age, sex, education, nativity, health behaviors, health care access, and comorbidities. We found significantly higher odds of diet counseling (African Americans, OR: 1.87; Asian Americans, OR: 3.02, AIAN, OR: 2.01), reduced sodium intake (African American, OR: 2.42), and adherence to exercise counseling (African American, OR: 3.52; Asian Americans, OR: 2.93). We also found lower odds of taking hypertension control medication (AIAN, OR: 0.50) and higher odds of hypertension‐related ED visits (African Americans, OR: 3.61, AIAN, OR: 5.31). These results highlight the success of health centers in managing hypertension by race/ethnicity but found adverse hypertension outcomes for some groups. Racial/ethnically tailored efforts might be required to manage hypertension and improve outcomes.     

Racial Differences in Long-Term Self-Monitoring Practice Among Newly Drug-Treated Diabetes Patients in an HMO

Background One approach to improving outcomes for minority diabetics may be through better self-care. However, minority patients may encounter barriers to better self-care even within settings where variations in quality of care and insurance are minimized. Objective The objective of the study was to evaluate racial differences in long-term glucose self-monitoring and adherence rates in an HMO using evidence-based guidelines for self-monitoring. Design Retrospective cohort study using 10 years (1/1/1993–12/31/2002) of electronic medical record data was used. Patients Patients were 1,732 insured adult diabetics of black or white race newly initiated on hypoglycemic therapy in a large multi-specialty care group practice. Measurements Outcomes include incidence and prevalence of glucose self-monitoring, intensity of use, and rate of adherence to national recommended standards. Results We found no evidence of racial differences in adjusted initiation rates of glucose self-monitoring among insulin-treated patients, but found lower rates of initiation among black patients living in low-income areas. Intensity of glucose self-monitoring remained lower among blacks than whites throughout follow-up [IRR for insulin = 0.41 (0.27–0.62); IRR for oral hypoglycemic = 0.75 (0.63, 0.90)], with both groups monitoring well below recommended standards. Among insulin-treated patients, <1% of blacks and <10% of whites were self-monitoring 3 times per day; 36% of whites and 10% of blacks were self-monitoring at least once per day. Conclusions Adherence to glucose self-monitoring standards was low, particularly among blacks, and racial differences in self-monitoring persisted within a health system providing equal access to services for diabetes patients. Early and continued emphasis on adherence among black diabetics may be necessary to reduce racial differences in long-term glucose self-monitoring.     

Abused Women Disclose Partner Interference with Health Care: An Unrecognized Form of Battering

BACKGROUND Some providers observe that partners interfere with health care visits or treatment. There are no systematic investigations of the prevalence of or circumstances surrounding partner interference with health care and intimate partner violence (IPV). OBJECTIVE To determine whether abused women report partner interference with their health care and to describe the co-occurring risk factors and health impact of such interference. DESIGN A written survey of women attending health care clinics across 5 different medical departments (e.g., emergency, primary care, obstetrics–gynecology, pediatrics, addiction recovery) housed in 8 hospital and clinic sites in Metropolitan Boston. PARTICIPANTS Women outpatients (N = 2,027) ranging in age, 59% White, 38% married, 22.6% born outside the U.S. MEASUREMENT Questions from the Severity of Violence and Abuse Assessment Scale, the SF-36, and questions about demographics. RESULTS One in 20 women outpatients (4.6%) reported that their partners prevented them from seeking or interfered with health care. Among women with past-year physical abuse (n = 276), 17% reported that a partner interfered with their health care in contrast to 2% of women without abuse (adjusted odds ratios [OR] = 7.5). Further adjusted risk markers for partner interference included having less than a high school education (OR = 3.2), being born outside the U.S. (OR = 2.0), and visiting the clinic with a man attending (OR = 1.9). Partner interference raised the odds of women having poor health (OR = 1.8). CONCLUSIONS Partner interference with health care is a significant problem for women who are in abusive relationships and poses an obstacle to health care. Health care providers should be alert to signs of patient noncompliance or missed appointments as stemming from abusive partner control tactics.     

Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients

Context Studies documenting racial/ethnic disparities in health care frequently implicate physicians’ unconscious biases. No study to date has measured physicians’ unconscious racial bias to test whether this predicts physicians’ clinical decisions. Objective To test whether physicians show implicit race bias and whether the magnitude of such bias predicts thrombolysis recommendations for black and white patients with acute coronary syndromes. Design, Setting, and Participants An internet-based tool comprising a clinical vignette of a patient presenting to the emergency department with an acute coronary syndrome, followed by a questionnaire and three Implicit Association Tests (IATs). Study invitations were e-mailed to all internal medicine and emergency medicine residents at four academic medical centers in Atlanta and Boston; 287 completed the study, met inclusion criteria, and were randomized to either a black or white vignette patient. Main Outcome Measures IAT scores (normal continuous variable) measuring physicians’ implicit race preference and perceptions of cooperativeness. Physicians’ attribution of symptoms to coronary artery disease for vignette patients with randomly assigned race, and their decisions about thrombolysis. Assessment of physicians’ explicit racial biases by questionnaire. Results Physicians reported no explicit preference for white versus black patients or differences in perceived cooperativeness. In contrast, IATs revealed implicit preference favoring white Americans (mean IAT score = 0.36, P < .001, one-sample t test) and implicit stereotypes of black Americans as less cooperative with medical procedures (mean IAT score 0.22, P < .001), and less cooperative generally (mean IAT score 0.30, P < .001). As physicians’ prowhite implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis (P = .009). Conclusions This study represents the first evidence of unconscious (implicit) race bias among physicians, its dissociation from conscious (explicit) bias, and its predictive validity. Results suggest that physicians’ unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction.     

Disparities in Oral Health Status Between Older Adults in a Multiethnic Rural Community: The Rural Nutrition and Oral Health Study

OBJECTIVES: To compare oral health status according to ethnicity and socioeconomic status in African-American, American-Indian, and white dentate and edentulous community-dwelling older adults.
DESIGN: Cross-sectional study; data from self-reports and oral examinations.
PARTICIPANTS: A multistage cluster sampling design was used to recruit 635 participants aged 60 and older from rural North Carolina counties with substantial African-American and American-Indian populations.
MEASUREMENTS: Participants completed in-home interviews and oral examinations. Self-reported data included sociodemographic indicators; self-rated oral health status; presence or absence of periodontal disease, bleeding gums, oral pain, dry mouth; and fit of prostheses. Oral examination data included number of teeth and numbers of anterior and posterior functional occlusal units.
RESULTS: African Americans and American Indians had significantly lower incomes and educational attainment than whites. Self-rated oral health was significantly better in whites than in African Americans and American Indians. Prevalence of self-reported periodontal disease and bleeding gums was lower in whites. Of dentate participants, African Americans were significantly more likely than whites to have 11 to 20 teeth and one or two posterior occlusal contacts. Oral health deficits remained associated with ethnicity when adjusted for socioeconomic variables.
CONCLUSION: Oral health disparities in older adults in a multiethnic rural area were largely associated with ethnicity and not socioeconomic status. Clinicians should be aware of these health disparities in oral health status and their possible role in disparities in chronic disease. Further research is necessary to understand whether these oral health disparities reflect current or lifetime access to care, diet, or attitudes toward oral health care.     

Understanding ethnic disparities in the use of total joint arthroplasty: application of the health belief model

OBJECTIVE: The Health Belief Model holds promise in understanding patient-related factors that may explain disparities in the use of total joint arthroplasty (TJA). We examined whether patients' health beliefs differ between African Americans and whites. METHODS: In a primary care clinic setting, 691 African Americans and whites with at least a moderately severe degree of osteoarthritis (OA) completed the Arthritis-related Health Belief Instrument. The instrument has 4 scales: perceived benefits of TJA, perceived barriers to obtaining TJA, perceived severity of arthritis, and perceived susceptibility of arthritis to worsen. RESULTS: The sample (40% women) consisted of 263 (38%) African Americans and 428 (62%) whites who were similar with respect to education, amount of insurance coverage, number of comorbidities, and self-report OA severity score. The African American group was younger, had less men, had more participants who reported an annual income<$15,000, and had a higher body mass index than whites. After controlling for confounders, African Americans were almost 50% (odds ratio [OR] 0.60, 95% confidence interval [95% CI] 0.42-0.86, P=0.005) as likely as whites to perceive that TJA is beneficial or helpful for their arthritis. Furthermore, African Americans were 70% (OR 1.7, 95% CI 1.18-2.44, P=0.004) more likely than whites to recognize barriers (e.g., risky, etc.) to TJA. Race was not associated with either the perceived severity or the perceived susceptibility of arthritis to worsen. CONCLUSION: Among patients with at least moderately severe OA, African Americans were significantly less likely than whites to perceive the benefits of TJA and more likely to recognize barriers to TJA.     

Behavioral Indices in Medical Care Outcome: The Working Alliance, Adherence, and Related Factors

Background  The working alliance has been shown to be a consistent predictor of patient outcome and satisfaction in psychotherapy. This study examines the role of the working alliance and related behavioral indices in predicting medical outcome. Objective  Cognitive and emotional dimensions of the physician–patient relationship were examined in relation to patients’ ratings of physician empathy, physician multicultural competence, perceived utility of treatment, and patients’ adherence self-efficacy. These factors were then examined as part of a theoretical framework using path analyses to explain patient self-reported adherence to and satisfaction with treatment. Design  The study was based on an ex-post facto field correlation design. Participants  One hundred fifty-two adult outpatients from a neurology clinic at Bellevue Hospital, a large municipal hospital in New York City, participated in the study. Interventions  Surveys given to participants. Measurements  We used the following measurements: Physician–Patient Working Alliance Scale, Perceived Utility Scale, Treatment Adherence Self-Efficacy Scale, Medical Outcome Study Adherence Scale, Physician Empathy Questionnaire, Physician Multicultural Competence Questionnaire, Medical Patient Satisfaction Questionnaire. Main Results  The effect sizes for adherence are between 0.07 and 0.21 and for satisfaction between 0.10 to >0.50. Regression and path analyses showed that ratings of physician multicultural competence and patient adherence self-efficacy beliefs predicted patient adherence (SB = 0.34) and (SB = 0.30) and satisfaction (SB = 0.18) and (SB = 0.12), respectively. Working alliance ratings also predicted patient satisfaction (SB = 0.49). Conclusions  Psychological and interpersonal dimensions of medical care are related to patient adherence and satisfaction. Medical care providers may be able to use these dimensions to target and improve health care outcomes.