Immigrant perceptions of discrimination in health care: the California Health Interview Survey 2003

BACKGROUND: U.S. healthcare disparities may be in part the result of differential experiences of discrimination in health care. Previous research about discrimination has focused on race/ethnicity. Because immigrants are clustered in certain racial and ethnic groups, failure to consider immigration status could distort race/ethnicity effects. OBJECTIVES: We examined whether foreign-born persons are more likely to report discrimination in healthcare than U.S.-born persons in the same race/ethnic group, whether the immigration effect varies by race/ethnicity, and whether the immigration effect is "explained" by sociodemographic factors. RESEARCH DESIGN: The authors conducted a cross-sectional analysis of the 2003 California Health Interview Survey consisting of 42,044 adult respondents. Logistic regression models use replicate weights to adjust for nonresponse and complex survey design. OUTCOME MEASURE: The outcome measure of this study was respondent reports that there was a time when they would have gotten better medical care if they had belonged to a different race or ethnic group. RESULTS: Seven percent of blacks and Latinos and 4% of Asians reported healthcare discrimination within the past 5 years. Immigrants were more likely to report discrimination than U.S.-born persons adjusting for race/ethnicity. For Asians, only the foreign-born were more likely than whites to report discrimination. For Latinos, increased perceptions of discrimination were attributable to sociodemographic factors for the U.S.-born but not for the foreign-born. Speaking a language other than English at home increased discrimination reports regardless of birthplace; private insurance was protective for the U.S.-born only. CONCLUSIONS: Immigration status should be included in studies of healthcare disparities because nativity is a key determinant of discrimination experiences for Asians and Latinos.     

Race, ethnicity, socioeconomic position, and quality of care for adults with diabetes enrolled in managed care: the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE: To examine racial/ethnic and socioeconomic variation in diabetes care in managed-care settings. RESEARCH DESIGN AND METHODS: We studied 7,456 adults enrolled in health plans participating in the Translating Research Into Action for Diabetes study, a six-center cohort study of diabetes in managed care. Cross-sectional analyses using hierarchical regression models assessed processes of care (HbA(1c) [A1C], lipid, and proteinuria assessment; foot and dilated eye examinations; use or advice to use aspirin; and influenza vaccination) and intermediate health outcomes (A1C, LDL, and blood pressure control). RESULTS: Most quality indicators and intermediate outcomes were comparable across race/ethnicity and socioeconomic position (SEP). Latinos and Asians/Pacific Islanders had similar or better processes and intermediate outcomes than whites with the exception of slightly higher A1C levels. Compared with whites, African Americans had lower rates of A1C and LDL measurement and influenza vaccination, higher rates of foot and dilated eye examinations, and the poorest blood pressure and lipid control. The main SEP difference was lower rates of dilated eye examinations among poorer and less educated individuals. In almost all instances, racial/ethnic minorities or low SEP participants with poor glycemic, blood pressure, and lipid control received similar or more appropriate intensification of therapy relative to whites or those with higher SEP. CONCLUSIONS: In these managed-care settings, minority race/ethnicity was not consistently associated with worse processes or outcomes, and not all differences favored whites. The only notable SEP disparity was in rates of dilated eye examinations. Social disparities in health may be reduced in managed-care settings.     

Ethnic differences in parents' perception of participatory decision-making style of their children's physicians

OBJECTIVES: The objectives of this study were to test whether there are ethnic differences in parents' perceptions of the participatory styles of their children's physicians, and to determine how Hispanic ethnicity influences the factors that are correlated with the perceptions of participatory styles. STUDY DESIGN: We conducted a population-based cross-sectional telephone survey in 111 counties of West Texas. Parents of children and adolescents 3 to 18 years of age (n = 3876) were included in analyses. METHODS: The participatory decision-making (PDM) style of physicians was measured by a 3-item instrument used in the Medical Outcomes Study. Multivariate analyses were performed to identify ethnic differences and whether the effect of independent variables on participatory style varied by ethnicity. RESULTS: The t test showed that the mean participatory decision-making score for Hispanics was significantly lower than that for non-Hispanic whites (P <0.01). However, the variance of the PDM score among Hispanics was greater than that among non-Hispanic whites using an F test (P = 0.03). After controlling for other independent variables, the effect of ethnicity was still significant. The association between PDM scores and a child's insurance and the parent's age varied by ethnicity. Parents' age, education, self-employment status, and income were associated with non-Hispanic white parents' perceptions of physicians' PDM, whereas children's insurance, parents' education and income were associated with Hispanic parents' perceptions of physicians' PDM (P <0.05). CONCLUSIONS: Because patient participation is closely related to health outcomes and patient satisfaction, improving Hispanic patients' participation can be 1 avenue for diminishing ethnic disparities in health. Further research is needed to establish whether ethnic differences in children's physicians' participation style exist from physicians' perspective and whether the differences are associated with physicians' characteristics.     

Older patients' health status and satisfaction with medical care in an HMO population

Few studies have examined the relationship between older patients' satisfaction with medical care and their health status, and none of these investigations has been based at an HMO. To examine this question, data on 532 patients older than 70 years in an HMO were analyzed. Patients' reports of satisfaction with medical care were examined in relation to several dimensions of health status (based on self-reports, chart data, and physicians' ratings), their own sociodemographic characteristics, and characteristics of their primary physicians. Greater satisfaction was significantly associated with better self-rated health and physical function, less emotional distress, and more social activity but was not related to physicians' health ratings, number of diagnoses, or cognitive function. Mean levels of satisfaction were also significantly different for patients of different physicians but not appreciably related to patients' sociodemographic characteristics. When patient sociodemographic characteristics were controlled for, the relations of health status variables to satisfaction were essentially unchanged. It was concluded that the key issues to be resolved are whether better health leads to greater satisfaction or vice versa, and, in either case, whether the relations are mediated by factors relating to the patient's experience of medical care.     

Provider satisfaction in clinical encounters with ethnic immigrant patients

OBJECTIVE: To determine whether physicians' satisfaction in clinical encounters with ethnic immigrant patients differs from satisfaction in clinical encounters with white patients in the local community. PATIENTS AND METHODS: Postvisit assessments from primary care physicians were collected for matched pairs of ethnic and control patients at the Mayo Clinic in Rochester, Minn, during a 10-week study (April 2-June 9, 2001). Ethnic patients were defined as first-generation Somalian, Cambodian, and Hispanic immigrants. Control patients were American-born white patients who were seen by the same physician and matched to the ethnic patients in age, sex, and type of visit. T tests and Hotelling T2 tests were used to analyze differences in physician responses between groups; regression analysis was used to identify the relationship between physicians' satisfaction and ethnicity in the presence of covariates. RESULTS: Physicians were considerably less satisfied with ethnic patient visits compared with control patient visits. Larger differences in satisfaction were reported in the areas of patient efforts with disease prevention and management of chronic diseases. Smaller differences in satisfaction were reported for issues related to communication and cultural beliefs and practices. These differences persisted after controlling for patient demographics, physician, and visit characteristics. CONCLUSIONS: Patients' ethnicity affects physician satisfaction with clinical encounters, particularly in the delivery of preventive care and chronic disease management.     

Inaccuracies in physicians' perceptions of their patients.

OBJECTIVE: The objective was to assess primary care physicians' awareness of their patients' rated emotions, satisfaction, and opinion of the quality of their communication. DESIGN: Diabetic patients (n = 261) and their primary care physicians (n = 44) each filled in a questionnaire following a routine medical visit. Patients were asked about the quality of communication with their physician, their satisfaction, and their experience of six emotions. Physicians were asked to estimate the patients' views on each of these questions. Physicians' awareness was measured by (1) correlating the physician and patient ratings, and (2) comparing mean ratings between physicians and patients. RESULTS: Correlations between patients' and physicians' views of patients' emotions and satisfaction were weak to moderate in magnitude; for patients' opinion of communication quality, there was no correlation. All ratings showed a substantial discrepancy between physicians and patients, such that physicians thought patients' responses were more negative than they actually were. CONCLUSIONS: Although the causes of physicians' weak awareness of their patients' responses are not known, the results suggest that the patients' affective responses may be an especially neglected aspect of communication in the medical visit.     

Attitudes toward health care providers, collecting information about patients' race, ethnicity, and language

BACKGROUND: Experts recommend that health care providers (HCPs) collect patients' race/ethnicity and language, but we know little about public attitudes towards this. OBJECTIVES: To determine attitudes towards HCPs collecting race/ethnicity and language data. PARTICIPANTS: A telephone survey was held with 563 Californians, including 105 whites, 97 blacks, 199 Hispanics (162 Spanish-speaking), 129 Asians (73 Chinese-speaking), and 33 multiracial individuals. MEASURES: Attitudes towards HCPs asking patients their race/ethnicity and preferred language, concerns about providing their own information, reactions to statements explaining the rationale for data collection, and attitudes towards possible policies. RESULTS: Most (87.8%) somewhat or strongly agreed that HCPs should collect race/ethnicity information and use this to monitor disparities, and 73.6% supported state legislation requiring this. Support for collection of patients' preferred language was even higher. However, 17.2% were uncomfortable (score 1-4 on 10-point scale) reporting their own race/ethnicity, and 46.3% of participants were somewhat or very worried that providing information could be used to discriminate against them. In addition, 35.9% of Hispanics were uncomfortable reporting their English proficiency. All statements explaining the rationale for data collection modestly increased participants' comfort level; the statement that this would be used for staff training increased comfort the most. CONCLUSIONS: Although most surveyed believe that HCPs should collect information about race/ethnicity and language, many feel uncomfortable giving this information and worry it could be misused. Statements explaining the rationale for collecting data may assuage concerns, but community engagement and legislation to prevent misuse may be needed to gain more widespread trust and comfort.     

CB7-01: Psychology in Primary Care: An Evaluation of Best Practices

Background/Aims Integrating psychology and mental health professionals into primary care settings has emerged as a means to improve the access to and utilization of mental health services. Three models linking psychology to primary care are: referring a patient to a psychologist located in a facility outside of the primary care physician's (PCP) office; referring a patient to a co-located psychologist who is not integrated into the PCP; integrated model where the PCP and the psychologist are co-located and communicate regarding the patient's health. The overall purpose of this project was to investigate predictors of patients' initial response patterns to their primary care physicians' referrals to psychologists across the Scott & White Healthcare system in the context of the models delineated. Methods Using clinician notes and claims data housed within the S&W electronic medical records (EMR), we identified patients with ICD-9 codes for depression (311, 300.4, 296.2, 296.3,) and anxiety disorder (308.3, 300.00) referred to mental health clinics those satisfy one of the three main psychology models mentioned above. Our main outcome variable of interest was patients' attendance at their initial appointment with psychologists (binary outcome variable yes/no). Patients' demographics (age, gender, race, ethnicity), clinics from which patients were referred, and the number of days between referral and scheduled appointment were included in the logistic regression model. Results Our preliminary results indicated that older patients were likely to attend initial appointments after being refereed by their PCP (odds ratio estimate=1.01, 95% CI: 1.006, 1.032). Patients that were seen by psychologist or mental health professional in a facility was integrated into the PCP practice were more likely (odds ratio estimate= 1.79, 95% CI: 1.12, 2.84) to attend their initial appointments compared to the other two models of care. Finally, patients with the greatest time between referral and time of scheduled appointments were less likely to attend their initial appointments. Discussion Results of this study provide useful information about how patients can receive effective mental healthcare services when the primary care physicians and psychologists work within an integrated co-located environment and communicate about the patient's health.     

Race/ethnic disparities in utilization of lifesaving technologies by Medicare ischemic heart disease beneficiaries

OBJECTIVE: The objective of this study was to explain race/ethnic disparities in hospitalizations, utilization of high-technology diagnostic and revascularization services, and mortality of elderly ischemic heart disease (IHD) patients. DESIGN: A longitudinal Medicare claims database of all Part A hospital and Part B physician services provided elderly patients admitted for IHD in 1997 is used to construct admission, utilization, and mortality rates for whites and blacks, Asians, Hispanics, and American Indians. Z-scores are used to test differences in rates between whites and minorities at the 99% confidence level. Logistic and proportional hazard models are used to predict the likelihood of revascularization and its effects on race/ethnic survival 2 years postdischarge. SETTING: The setting of this study was an acute hospital supplemented by all ambulatory Part B outpatient providers of care. PATIENTS/PARTICIPANTS: Participants included all 700,000 age 65+ Medicare beneficiaries in fee-for-service identified with IHD as a primary diagnosis on admission in 1997. MEASUREMENTS AND MAIN RESULTS: Whites were 26% more likely to be admitted for IHD than blacks, 50% more likely than Asians, 5% more than American Indians, but 3% less likely than Hispanics. Once admitted, elderly blacks and American Indians undergo invasive diagnostic and surgical revascularization far less often than whites (P < 0.01), although blacks are equally as likely as whites to be admitted to an open heart hospital. Controlling for other factors, whites reduce their 2-year mortality by 20% by undergoing revascularization 41% of the time. Blacks gain only 11% as a result of much lower rates and gains to revascularization than whites. Asians and Hispanics were slightly more likely than whites to undergo revascularization but gain less than whites from the procedure. CONCLUSIONS: Despite having similar Medicare health insurance coverage, elderly utilization and IHD mortality rates differ markedly not only between whites and minorities, but within minority groups themselves. A large, nationally representative survey of physicians and patients is needed to distinguish between systemwide "failures to refer" and patient "aversions to surgery" as explanations for lower black rates of surgical interventions.     

Pain, disability, and satisfaction outcomes and predictors of outcomes: a practice-based study of chronic low back pain patients attending primary care and chiropractic physicians

BACKGROUND: Few studies exist on the prognostic value of demographic, clinical, or psychosocial factors on long-term outcomes for patients with chronic low back pain. OBJECTIVE: This study reports on long-term pain and disability outcomes for patients with chronic low back pain, evaluates predictors of long-term outcomes, and assesses the influence of doctor type on clinical outcome. METHODS: Sixty chiropractic (DC) and 111 general practice (MD) physicians participated in data collection for a prospective, longitudinal, practice-based, observational study of ambulatory low back pain of mechanical origin. The primary outcomes, measured at 6 months and 12 months, were pain (by using the Visual Analog Scale), and functional disability (by using the Revised Oswestry Disability Questionnaire). Satisfaction was a secondary outcome. RESULTS: Overall, long-term pain and disability outcomes were generally equivalent for patients seeking care from medical or chiropractic physicians. Medical and chiropractic care were comparable for patients without leg pain and for patients with leg pain above the knee. However, an advantage was noted for chronic chiropractic patients with radiating pain below the knee after adjusting for baseline differences in patient and complaint characteristics between MD and DC cohorts (adjusted differences = 8.0 to 15.2; P <.002). A greater proportion of chiropractic patients were satisfied with all aspects of their care (P =.0000). The strongest predictors of primary outcomes included an interaction of radiating pain below the knee with provider type and baseline values of the outcomes. Income, smoking, comorbidity, and chronic depression were also identified as predictors of outcomes in this study. CONCLUSION: Chiropractic care compared favorably to medical care with respect to long-term pain and disability outcomes. Further study is required to explore the advantage seen for chiropractic care in patients with leg pain below the knee and in the area of patient satisfaction. Identification of patient and treatment characteristics associated with better or worse outcomes may foster changes in physicians' practice activities that better serve these patients' needs.     

Are there race/ethnicity differences in outpatient congestive heart failure management, hospital use, and mortality among an insured population?

OBJECTIVE: The objective of this study was to assess the quality of outpatient care received by patients with congestive heart failure (CHF) and whether differences in care and outcomes exist by race/ethnicity. BACKGROUND: Appropriate outpatient CHF management can improve patient well-being and reduce the need for costly inpatient care. Yet, little is known regarding outpatient CHF management or whether differences in this care exist by race/ethnicity. METHODS: Using automated data sources, we identified a cohort of insured patients seen in an outpatient setting for CHF between September 1992 and August 1993. Medical record abstraction was used to confirm diagnosis of CHF. Patients (N = 566) were followed until September 1998. Race/ethnicity differences in outpatient management and medical care utilization were assessed using generalized estimating equations. Differences in mortality and hospitalization for CHF, controlling for patient characteristics and outpatient management, were assessed using Cox and Andersen-Gill models, respectively. RESULTS: With the exception of beta blocker use and primary care visit frequency, few differences by race/ethnicity in patient characteristics and CHF management were found. However, older black patients had more hospital use both at baseline and during follow up. These differences persisted after adjusting for patient characteristics and clinical management. No race/ethnicity differences were found in mortality. CONCLUSIONS: In an insured population, older black patients with CHF have substantially more hospital use than older white patients. This increased use was not explained by differences in CHF outpatient management. Further research is needed to understand why race/ethnicity differences in hospital use are observed among older patients with CHF.     

Patient satisfaction with nurse practitioner-delivered primary healthcare services

Purpose: To identify levels of satisfaction with nurse practitioner (NP)-delivered primary healthcare services and to determine demographic differences in degrees of general satisfaction reported by patients.
Data sources: The Nurse Practitioner Satisfaction Survey (NPSS), a 28-item, 5-point, Likert-type survey instrument was developed; data from 300 female and male clients over 18 years of age presenting for primary healthcare visits at the employee health department of a not-for-profit hospital in the Southern United States were analyzed.
Conclusions: Although many studies using a variety of healthcare-related patient satisfaction instruments have demonstrated acceptable patient satisfaction with NPs, few have investigated patient satisfaction with NPs in the outpatient primary care occupational health arena. Overall the population seeking health care was satisfied with NP services. In particular, married or cohabitating subjects reported general satisfaction scores that were statistically significantly higher than those who were single and never married. No other differences were found.
Implications for practice: The provision of on-site, employer-sponsored NP primary healthcare services that are perceived as acceptable and satisfactory to employees and families affords significant opportunity and advantage to both employee and employer. Such benefits include enhanced employee and family wellness, facilitated health promotion, enhanced access to care, reduced illness related to time away from work, improved employee productivity, and reduced overall organizational healthcare costs. Knowledge regarding those characteristics contributing to general satisfaction with NP-delivered care serves to facilitate practice pattern changes within the profession that further enhances the visibility, utilization, and acceptability of NPs as primary care providers.     

The measurement of patient satisfaction

Patient satisfaction is an important quality outcome indicator of health care in the hospital setting. The measurement of patients' satisfaction with nursing is particularly important since nursing service is often a primary determinant of overall satisfaction during a hospital stay. This article reports on a study designed to update and revise the definition of patient satisfaction for application with ambulatory surgical patients and to develop a questionnaire that captures this definition. The Patient Satisfaction Scale, which specifically focuses on patient satisfaction with nursing care and is used extensively by nursing researchers, was selected for factor analytical examination. Psychometric testing resulted in a 15-item scale with three underlying dimensions.     

Satisfaction with care among patients with diabetes in two public health care systems.

OBJECTIVES: We compared patient satisfaction among adults with diabetes treated in a Veterans Affairs (VA) health care system with the satisfaction of patients treated in a county-funded health care system. We also examined whether satisfaction differences reflected differences in the process of patient care. DESIGN: Cross-sectional telephone survey of patients recruited from outpatient clinics. SUBJECTS: Five hundred and thirty eight adults, including 310 patients from 4 VA clinics and 228 patients from 2 county clinics. MEASURES: Overall satisfaction with care and satisfaction with 6 separate dimensions of care were measured using the Employee Health Care Value Survey. RESULTS: VA patients were more satisfied than were county patients overall and with 5 of 6 dimensions of their care. These differences increased when we adjusted for patients' sociodemographic and clinical characteristics. VA patients reported more diabetes counseling and shorter waiting times to see their doctor. Each of these self-reported process measures was positively correlated with satisfaction and, when taken into account, reduced the differences in satisfaction between the two systems. However, even when we controlled both for patient characteristics and the process of care, VA patients still were more satisfied than were county patients with their care overall as well as with their access to care, communication with providers, and the quality of their health outcomes. CONCLUSIONS: In this study, VA patients with diabetes were more satisfied with their health care than were county patients. Perceived diabetes-related counseling and shorter waiting times contributed to differences between the systems in patient satisfaction but did not explain them completely.     

Racial variation in the control of diabetes among elderly medicare managed care beneficiaries

OBJECTIVE: To examine racial variation in the poor control of GHb, a GHb value >9.5%, or GHb not tested in 1999 among Medicare beneficiaries aged 65-75 years enrolled in managed care plans. RESEARCH DESIGN AND METHODS: The National Committee on Quality Assurance provides person-level data regarding diabetes care services and control for Medicare beneficiaries enrolled in managed care to the Centers for Medicare and Medicaid Services (CMS). We merged this information with information on each individual's race, as well as other person-level and plan-level characteristics obtained from CMS. Bivarate and multivariate analyses were performed. RESULTS: The overall rate of poor GHb control was 32.7%. The age- and sex-adjusted rate of poor control among whites was 32.0%. This rate was significantly higher than the rate among Asians (24.7%) but significantly lower than the rate among blacks (40.6%) and Hispanics (36.5%) (P < 0.001). An increase in the number of comprehensive diabetes care measures received by an individual was associated with a significantly lower percentage of individuals with poor GHb control in all race groups. After controlling for the individual-level, plan-level, and diabetes care measure variables, the difference in GHb control between Asians and whites disappeared. However, blacks and Hispanics continued to have significantly higher rates of poor control than whites. CONCLUSIONS: There is room for significant reduction in the number of patients with poor control of GHb among all races, particularly among blacks and Hispanics.     

Patient satisfaction associated with correct identification of physician's photographs

OBJECTIVE: To determine whether placement of photographs of physicians in hospital rooms improves patients' satisfaction with their medical care. PATIENTS AND METHODS: This is a prospective, controlled study of 224 patients admitted to general internal medicine services in a teaching hospital. The intervention consisted of photographs (8 x 10 in) of attending and resident physicians displayed in the patients' rooms. Before dismissal, patients completed a survey that required them to match names with photographs of physician caregivers and included patient satisfaction questions. The primary outcome was whether patients who had photographs in their hospital room would correctly identify more physicians than those with no photographs in their room. RESULTS: The presence of photographs on the hospital wall was associated with a significant improvement in the number of physicians identified correctly (odds ratio [OR], 1.83; 95% confidence interval [CI], 1.47-2.27; P<.001). The percentage of physicians that patients identified by correctly matching their physicians' names to their photographs was significantly associated with satisfaction with physician responsiveness (OR, 1.19; 95% CI, 1.01-1.40; P=.03) and with the way in which physicians addressed questions regarding medical care (OR, 1.23; 95% CI, 1.05-1.44; P=.05). CONCLUSIONS: Patients who had photographs of their physicians on the wall of their hospital room were able to identify correctly a larger number of physicians on their team compared with patients who had no photographs. Patient satisfaction was related to the number of physicians' photographs that patients could identify correctly.     

Patient race and ethnicity in primary care management of child behavior problems: a report from PROS and ASPN. Pediatric Research in Office Settings. Ambulatory Sentinel Practice Network.

BACKGROUND: Minority persons have less access to many specialty treatments and services, possibly because of clinician biases. It is not clear whether any such biases exist in primary care settings, especially for children with psychosocial problems. OBJECTIVES: The objective was to compare primary care recognition and treatment of pediatric psychosocial problems among African American, Hispanic American and European American patients. DESIGN: A survey was made of parents and respective clinicians in primary care offices in two large practice-based research networks (PROS and ASPN) from 44 states, Canada, and Puerto Rico. Mixed regression analyses were employed to control for patient, clinician, and practice effects. SUBJECTS: The subjects were 14,910 children aged 4 to 15 years seen consecutively for non-emergent care by 286 primary care clinicians in office-based practice. MEASURES: Measures were parents' report for sociodemographics and behavioral symptoms using the Pediatric Symptom Checklist, and clinicians' report of psychosocial problems, type, management, and severity. RESULTS: Of the sample, 8.0% were African American youth, 9.5% were Hispanic American youth, and 82.5% were European American youth. After controlling for other factors, race and ethnicity were not associated with any differences in psychotropic drug prescribing, counseling, referral, or recognition of psychosocial problems. Clinicians reported spending slightly more time with minority patients. CONCLUSION: Race and ethnic status were not related to receipt of mental health services for children in primary care offices, suggesting that clinician biases may not be the primary cause of the racial differences in services noted earlier research. Improving services for minority youth may require increasing access to office-based primary care.