Socioeconomic and Racial/Ethnic Differences in the Discussion of Cancer Screening: Between- vs. Within- Physician Differences Yuhua Bao, Ph.D., Sarah Fox, Ed.D., Jose Escarce, M.D., Ph.D. Center for Community Partnerships in Health Promotion, UCLA General Internal Medicine/Health Services Research UCLA GIM/HSR Funded by the NIH EXPORT Center at UCLA/DREW (YB), NCI (SAF) and AHRQ (JE)

2 Socioeconomic and Racial/Ethnic Disparities in Cancer and Cancer Screening Recent years saw steady decline in cancer death rates and improvement in cancer survival However, disparities by patient socioeconomic status (SES) are substantial in Adherence with cancer screening guidelines Stage of diagnoses Mortality and survival Differences by patient race/ethnicity are less consistent, but Mortality from all cancers is highest among Blacks

3 The Role of Physician-Patient Communication Differential adherence to cancer screening is partly due to differences in access to care. However, Disparities in cancer screening utilization exist even among people with a usual source of care People of low-SES more likely to cite I didnt know I need it and Dr did not recommend it as barriers to cancer screening (Finney et al. 2003) Disparities in cancer screening communication may have played a role

4 The Within- vs. Between- Physician Differences Once patients get access to health care, treatment disparities arise because Patients of different SES or race/ethnicity are treated differently by the same physicians (within-physician differences), AND / OR They are treated by a different group of physicians (between-physician differences)

5 Within-physician Differences

6 Possible Mechanisms for Within- Physician Differences Patient-level factors Low-SES and/or racial/ethnic minority patients are less aware of the need for cancer screening (Finney et al. 2003) They are less assertive / proactive in clinical encounters Physician-level factors Physicians may perceive them to be less interested (van Ryn and Burke 2000) Physicians may have greater difficulties in assessing their needs and preferences (Balsa and McGuire 2001; 2003) Patient-physician interaction Patient preferences and physician attitudes and perceptions are reinforced (IOM 2002)

7 Between-physician Differences Dr. A Dr. B

8 Possible Mechanisms for Between- Physician Differences Physicians serving disproportionately more minority or low-SES patients May be less well trained Are less likely to be board-certified (Bach et al. 2004) Are more likely to be foreign medical school graduates (Bellochs and Carter 1990) May be less knowledgeable about national preventive care guidelines (Ashford et al. 2000) They may also have less resources in the community such as Specialty groups with cancer screening capabilities Institutional support for preventive care Some of the within-physician differences may be reinforced to become practice patterns

9 Research Question How much of the differences in cancer screening discussion were due to within- vs. between- physician differences?

10 Data: the Communication in Medical Care (CMC) Studies A research series that promotes physician-patient communication on important preventive care topics Aimed at developing and testing a physician-patient communication model to change patient health behaviors The second and third studies in the series (CMC2&3) are both randomized controlled community trials that Teach the model in a Continuing Medical Education (CME) program Focused on cancer screening behaviors

11 Data: Patient and Physician Samples Physicians: office-based, primary care, practicing at least 50% of the time CMC2: Los Angeles County CMC3: all southern California except LA County Patients: having seen and expect to see study physician regularly, speaking either English or Spanish CMC2: CMC3: Data pooled from CMC2&3 baseline Physicians: N=191 Patients: N=5978 On average, patients had seen their physicians for 5 years Number of patients per physician: mean=31, median=30, range: [2, 83]

12 Outcomes of Interest: Cancer Screening Discussion Did Dr. ever talk to you about … Rate of Discussion (%) Fecal Occult Blood Test (FOBT)36.8 Sigmoidoscopy30.9 Mammogram (female only)67.1 Prostate Antigen Test (PSA) (male only; CMC2) 46.0

13 Statistical Strategies Probit model of cancer screening discussion Two specifications for each cancer screening discussion outcome Model 1: Patient characteristics only to assess the overall differences Model 2: Model 1 + Physician Fixed Effects Differences that remain reflect within-physician differences Between-physician differences=Overall – Within We report probabilities of discussion for each racial/ethnic or SES group compared to a reference group Bootstrapped standard errors (and p-values) to provide statistical inferences

14 By Education: Discussion of FOBT * p <0.05; ** p<0.01 Compared to college graduates

15 By Education: Discussion of Mammogram * p <0.05; ** p<0.01 Compared to college graduates

16 By Education: Discussion of PSA * p <0.05; ** p<0.01 Compared to college graduates

17 By Income: Discussion of FOBT * p <0.05; ** p<0.01 Compared to annual income of $75+

18 By Income: Discussion of Mammogram * p <0.05; ** p<0.01 Compared to annual income of $75+

19 By Income: Discussion of PSA * p <0.05; ** p<0.01 Compared to annual income of $75+

20 Summary of findings Disparities by education Strong education gradient in the discussion of all three types of cancer screening Most of the education differences arose within physicians Disparities by income Less consistent across different screening methods, but Seemed to have arisen because of between- physician differences Differences by race/ethnicity Asian/white differences in the discussion of FOBT and PSA were mostly within-physician differences Same physicians were much more likely to have discussed mammogram with black than white patients

21 Study Limitations Patient self-report of clinical encounter experience may not be consistent with what really happened If low-SES patients tend to under-report physicians discussion Both within- and between- differences by SES are biased up But hard to say how that might change the relative magnitude of the two types of differences It depends on the distribution of low (vs. high) SES patients across physicians On the other hand, it is arguable that what patients recall is what matters Small sample sizes for some racial/ethnic groups Findings regarding racial/ethnic differences should be interpreted with caution

22 Implications Patient education plays an important role in determining what happens in a clinical encounter Tailor patient informational materials to the needs of low- education patients Raise the awareness of physicians about the challenges faced by low-education patients Physicians are not evenly distributed across communities of different levels of income Targeting physicians practicing in low-income communities may be especially promising Geographic accessibility of providers is important to low- income patients