Assessing the Role of the Physician and Practice Setting in Child Health Disparities Lauren A. Smith 1, Andrew Johnson 2, Carol J. Simon 2 1 Boston University School of Medicine 2 Abt Associates and Boston University School of Public Health Supported by grants from Agency for Healthcare Research and Quality, The California Endowment & The Commonwealth Fund

Research Objectives To examine clinical decision making for 2 pediatric conditions with a high degree of clinical discretion To identify any racial/ethnic differences in clinical decision making To explore the association of physician and practice characteristics with decision making and any disparities

Study Design & Population Studied Mixed-mode (mail, web) survey Random sample of 1,500 primary care physicians from AMA Physician Masterfile N=771 pediatric providers 5 states: CA, GA, IL, PA, TX Minority MDs over-sampled ~15% African American and/or Hispanic Fielded January-May % response rate Practice questions plus clinical vignettes

Survey Data Domains Practice & patient characteristics Location Payer types Racial/ethnic composition of patient population Limited English proficiency MD characteristics Race/ethnicity Gender Age Time since graduation

Race/Ethnicity Variation in Vignettes VignetteNameRace/ethnicity 1aElenaLatina 1bAishaAfrican American 1cKristenWhite 2aJoséLatino 2bDarnellAfrican American 2cToddWhite

Vignette 1 NAME, a previously healthy 13 yo RACE/ETHNICITY girl, sees you for the evaluation of stomach pain, headaches and fatigue. Her mother says her daughter often complains about being sick. She had been an above-average student, but now gets poor grads. She often naps during the day and recently quit the school chorus because she was “too tired”. She has difficulty sleeping. She denied alcohol or drug use. Recent medical evaluation, including blood work was normal. The patient lives with brother and sister. PE: Height 50%ile; weight 75%ile, up 8 pounds since last year. She is quiet during the interview and says she “feels fine”. The remainder of PE is normal.

Vignette 1 Results by Race Clinical management Total N=771 % White N=260 % Black N=251 % Latino N=260 % Dx=adolescent response very likely Dx=depression very likely Observe Refer to mental health provider No medical therapy Start anti-depressant

Vignette 1 Results by Practice/Patient Characteristics Clinical managementLatino PatientsBlack patients <20% N=296 %  40% N=211 % <20% N=466 %  40% N=73 % Dx=adolescent response very likely Dx=depression very likely * Observe, reassess Refer to mental health provider * No medical therapy Start anti-depressant

Vignette 1 Results by Practice/Patient Characteristics Clinical managementLEP PatientsMedicaid patients <20% N=463 %  40% N=121 % <20% N=355 %  40% N=225 % Dx=adolescent response very likely 2128*2129* Dx=depression very likely Observe, reassess1424*1418 Refer to mental health provider 7366*7464* No medical therapy8188**8481 Start anti-depressant

Vignette 2 NAME, a 9 yo RACE/ETHNICITY boy, arrives with his mother for a new patient visit. He was diagnosed with asthma 2 yrs ago. In the past year, he has had 2 ED visits, 1 hosp, and 1 short course of oral steroids. He has some wheeze & cough 2-3 times/week and awakes once or twice/month w/ cough. His mother states “it doesn’t seem to bother him.” He gets albuterol nebs for his coughing & wheezing episodes. One older sibling w/ history of wheezing. No drug, food or seasonal allergies. There is a cat at home. Mother smokes. PE: Wt for ht is above 75%ile. No audible wheezing.

Vignette 2 Results by Race Clinical managementTotal N=771 % White N=260 % Black N=251 % Latino N=260 % Dx=mild persistent Dx=mod persistent Check peak flow Asthma action plan Refer to asthma specialist Inhaled corticosteroids seasonally/short period Inhaled corticosteroids year round

Vignette 2 Results by Practice/Patient Characteristics Clinical managementLatino PatientsBlack patients <20% N=296 %  40% N=211 % <20% N=466 %  40% N=73 % Dx=mild persistent * Dx=mod persistent Check peak flow6576*7356* Asthma action plan8491*8783 Refer to asthma specialist ** Inhaled corticosteroids seasonally/short period Inhaled corticosteroids year round

Vignette 2 Results by Practice/Patient Characteristics Clinical managementLEP PatientsMedicaid patients <20% N=463 %  40% N=121 % <20% N=355 %  40% N=225 % Dx=mild persistent * Dx=mod persistent * Check peak flow6579*6873 Asthma action plan ** Refer to asthma specialist * Inhaled corticosteroids seasonally/short period Inhaled corticosteroids year round

Conclusions Substantial variation reported in clinical management of childhood depression and asthma No variation noted based on race/ethnicity of patient in vignette Practice characteristics associated with differences in clinical decision making Physicians who had high proportion of black patients or Medicaid-insured patients were less likely to refer to specialists

Limitations Vignettes may not reflect true decision making practices Triggers in vignettes may not have been sufficient to trigger differences in decision making Sample from 5 states may not be generalizable to all pediatricians