1. Patient-physician racial concordance, effectiveness of care, use of services, and patient satisfaction Thomas R. Konrad, Ph.D. 1 Daniel L. Howard, Ph.D. 2 1 University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research, UNC-CH 2 Shaw University

2. Background: Racial disparities exist in the health care workforce Racial and ethnic minorities are under represented in the medical workforce when compared to their representation in the population

3. Three arguments for increasing numbers of minority health professionals.... Fairness: –Providing equal opportunity for disadvantaged minorities Access: –Making health services available to underserved communities and patients. Effectiveness: –Increasing the effectiveness of care received by minority communities and patients

4. Fairness : It’s the right thing to do This argument is based on fairness and justice to providers not communities or patients No necessity to argue about “health” or “health care” issues.

5. Access Minority physicians are more likely than others to serve poor, under-served, minority, and rural areas. Access to some care is better than no care (Bernard 1997); minority physicians are more likely to provide that access. Assumes that a public good is at stake

6. Effectiveness Argues that racial concordance between patients and providers makes delivery of care work better. –African American patients require African American physicians because they understand the cultural and social context of illness in the African American community. –Better communication and understanding may resulte in better health outcomes and more effective care Arguments about effectiveness are more appealing to policy makers in a climate of fiscal restraint

9. Policy questions Do providers beliefs about patients affect their behavior? –Conscious and unconscious –“Stereotyping” Race ethnicity can be confounded with clinical condition, site, payer

10. The purpose of this line of research is to ask: Do African American patients receive more effective care from African American physicians than do similar patients with White physicians? How do both groups of African American patients compare with white patients receiving care from either White or African-American physicians?

11. Our first study... Examined a sample of elderly African American and White respondents to the a community based survey, Identified their usual care physician (whether African American or White), if they had one Omitted individuals without a regular physician (respondents without doctors are disproportionately African-American) Assessed the impact of Patient-physician relationship using several patient care outcome measures.

12. Today’s presentation Reviews initial reports on results of a cross sectional study using patient-physician concordance by race in a follow-up sample. Describes the data and analysis plan for ongoing longitudinal studies of patient- physician racial concordance on effectiveness of care. Alludes to issues of continuity of care in subsequent planned research.

13. Summary of previous study Citation: Howard DL, Konrad TR, Stevens C, Porter CQ. Physician-patient racial matching, effectiveness of care, use of services, and patient satisfaction. Research on Aging. 2001, (Jan) 23(1):83-107.

14. Constructing the dataset: EPESE (Master) dataset –1986-87 study population –over-sampling of African Americans and geographic areas –4,162 survey respondents NC-BME physician files –All licensed MDs –Demographic and training information from annual re-licensure surveys. Our ANALYTIC dataset –2,867 Ss 1,416 African Americans 1,451 Whites 34 African American physicians 243 White physicians –1,295 respondents did not meet criteria

15. Independent and control variables: physician level: race age gender Experience: –(yrs. from med school grad) board-certified (yes / no) Generalist vs. specialist –1st or 2nd specialty in FP, GP, or IM Community Health Center as practice location?

16. Independent & control variables: patient level: race age gender education marital status currently working? yearly income insurance status (Medicaid, Medi-gap, none ) rural versus urban illness index disability index self-reported health

17. Dependent Variables Presence of & care for hypertension: –Actual recorded blood pressure –Told that you had high blood pressure? –Given medication for high blood pressure? –Currently taking high blood pressure medication? Other indicators of patterns of care –Fragmentation: ER visits > 10% total visits in 12 mth period –Access Delaying care quite often –Satisfaction Satisfied vs. dissatisfied with care (1 item)

18. Analytic approach: cross-sectional study sample weights not utilized patients clustered by their physician illness index excluded in analyses pertaining to blood pressure monitoring chi-square, analysis of variance, and logit tests used on all descriptive comparisons multivariate logistic and ordered logit regressions with adjustments for clustering used

19. Patient-physician racial dyads 31 African American doctors served 720 African Americans (25%) 87 White doctors served 696 African Americans (24%) 3 African American doctors served 36 Whites (1%) 156 White doctors served 1,415 Whites (49%)

20. physicians (by race) No differences by race by physician gender, age, and experience (yrs. since medical school) AA MDs more likely FP, GP, IM (p<.002) AA MDs more likely to work in CHC (p<.001) AA MDs less likely to be board-cert (p<.001)

21. African American patients with African American physicians physicians: most likely to: –be 65 years old or older (19%) –specialize in FP, GP, or IM (87%) –live in same county as patient (68%) patients: no extremes

22. White patients with African American physicians physicians: most likely to: be male and btw 36-64 yrs old (100%) work at a CHC (33%) least likely to: have experience (13.7 yrs) have board-certification (0%) live in same county as patient (0%)

23. White patients with African American physicians patients: most likely to: reside in rural area (75%) have disabilities (17%) report poor health (40%) least likely to: have high income ( none w/ > $20,000 / yr ) be married (31%)

24. African American patients with White physicians Physicians: most likely to: –be 35 years old or below (37%) least likely to: –be male (78%)

25. African American patients with White physicians patients: most likely to: –have Medicaid (14%) least likely to: –have Medi-gap (31%) –high education (7th grade+)

26. White patients with White physicians physicians: most likely to: –have more experience (22.6 years) –be board-certified (78%) least likely to: –Be a generalist (FP, GP, or IM (57%) –work in a CHC (2%)

27. White patients with White physicians patients: most likely to: –be more educated (10.1 years) –have higher income (19% at >$20k) –have Medi-gap insurance (78%) –be married (43%) –report good or excellent health (60%) least likely to: –have Medicaid insurance (3%) –have disabilities (11%) –live in a rural area (58%)

28. Bivariate results: Racial dyads & dependent variables only There were only a SMALL number of White patients w/ African American physicians. White patients w/ African American physicians were more likely to be told of high blood pressure (47%) and given high blood pressure medication (42%) and currently taking high blood pressure medication (37%) White patients w/ African American physicians are more likely to delay care (33%), be very dissatisfied w/ care (11%) and are least likely to be very satisfied w/ care (17%) The opposite is true for White patients w/ White physicians; white patients w/ white physicians put off care least (14%) and are most likely to be very satisfied w/ care (43%) No differences across the 4 groups in actual blood pressure being high, ER visits / total visits, and being dissatisfied w/ care.

29. Multivariate results: Y= measured* high blood pressure Positive predictors: diabetics (p<.01) Negative predictors : married (p<.01) Medicaid (p<.05) * Field measurement at the time of the survey

30. Multivariate results: Y= ever been told you have high blood pressure Positive predictors: African American patients with –African American physicians (p<.001) –White physicians (p<.001) medi-gap insurance (p<.001) diabetes (p<.001) stroke (p<.001) poor self-reported health (p<.01) Negative predictors: males (p<.001) older patients (p<.05)

31. Multivariate results: Y= Ever been given high blood pressure meds Positive predictors: African American patients –with white physicians (p<.01) older patients (p<.01) poor self-reported health (p<.01) Negative predictors: males (p<.05)

32. Multivariate results Y= currently taking high blood pressure meds Positive predictors: none Negative predictors: males (p<.05) cancer patients (p<.05)

33. Multivariate results Y = delaying care quite often Positive predictors: White patients w/ African American physicians (p<.01) married (p<.05) poor self-reported health (p<.001) those w/ physicians w/ more experience (p<.05) Negative predictors: African American patients –White MD (p<.05) males (p<.001) older patients (p<.001) more educated (p<.05) those w/ poorer health (p<.01)

34. Multivariate results Y = More than 10% of total visits are to ER Positive predictors: Medicaid insurance (p<.01) illness index (p<.001) disabilities (p<.05) poor self-reported health (p<.001) Negative predictors: education (p<.01)

35. Multivariate results:* Y= satisfaction w/ care Positive predictors: education (p<.01) income (p<.001) w/ physician 65+ yrs old (p<.001) w/ physician between 36-64 yrs old (p<.01) Ordered logit model

36. Multivariate results:* Y= satisfaction w/ care Negative predictors: African American patients with –African American physicians (p<.01) –white physicians (p<.05) married (p<.001) poor self-reported health (p<.001) has a male physician (p<.001) has a physician who works in CHCs (p<.05)

37. Conclusions of first study Minimal differences between African American and White physicians in patterns of care delivery. Age and gender of physician is important for patient satisfaction. Higher satisfaction among African American patients with white doctors than with African American doctors. Least satisfaction among White patients with African American doctors (small numbers).

38. Conclusions (cont.) The higher level of satisfaction among African American patients occurred with White physicians … a group of physicians more likely to be female … a group of patients more likely to be female.

39. Limitations of the first study One patient-physician dyad had only36 patients and 3 physicians Cross-sectional data and therefore causality between independent and dependent variables could not be established Limited to one time period (1986)

40. New Study Addresses previous limitations Longitudinal analyses possible Better satisfaction measure available Effects of continuity of care (having SAME physician) can be addressed in addition to the issue of patient-physician racial concordance.

41. Patient-physician racial dyads 34 African American doctors served 462 African Americans (21%) 110 White doctors served 602 African Americans (27%) 2 African American doctors served 30 Whites (1%) 162 White doctors served 1,142 Whites (51%)

42. physicians (by race) No differences by race by physician gender or experience (yrs. since medical school) AA MDs more likely 65+ years old (p<.001)

43. Bivariate results: Racial dyads & dependent variables only There were only a SMALL number of White patients w/ African American physicians. No differences across the 4 groups in actual blood pressure being high. White patients w/ white physicians were least likely to be told of high blood pressure (55%). African American patients w/ African American physicians were more likely to be told of high blood pressure (85%). White patients w/ African American physicians were least likely to be very satisfied w/ care (10%), while white patients w/ white physicians were most likely to be very satisfied w/ care (40%). Satisfaction w/ care remained the same between 1986 and 1990 for African Americans w/ African American physicians, while the other dyads experienced decreases in satisfaction over the years.

44. High Satisfaction w/ Care 1986-1990 19861990 African American patient w/ African American MD 27% White patient w/ African American MD 17%10% African American patient w/ White MD 34%25% White patient w/ White MD 43%40%

45. Continuity of Care Same MD in Year 2 If different MD, is race of MD different from Year 1? African American patient w/ African American MD 52%22% White patient w/ African American MD 27%60% African American patient w/ White MD 45%28% White patient w/ White MD 61%10%

46. Initial thoughts regarding second study Again, minimal differences between African American and White physicians in patterns of care delivery. High satisfaction among African American patients with white doctors dramatically decreased in 1990 vs. 1986 (34% vs. 25%). High satisfaction among African American patients w/ African American doctors remained constant between 1986 and 1990 (27%). Greater continuity of care (having the same physician over time) among same-race patient-physician dyads.

47. Preliminary analyses from new study Measure satisfaction in a more sophisticated way Special sensitivity to an aging population

48. Satisfaction items Doctors always do their best to keep patients as old as I am from worrying Doctors always treat their patients my age with respect. Sometimes doctors make patients my age feel foolish.

49. Satisfaction items When treating people about my age doctors always avoid unnecessary patient expenses. Doctors often cause patients my age to worry a lot, because they don’t explain things well. When treating people about my age, doctors respect their patients’ feelings.

50. Satisfaction items Doctors never recommend an operation for people my age, unless there is no other way to solve the problem. Doctors don’t pay enough attention to the health problems that people my age have. Most of these younger doctors really understand how people my age feel. Sometimes doctors think that just getting old is a disease that can’t be cured.

51. Differences among those without physicians in 1990 Proportion “agree” or “strongly agree with descriptions of doctors. Dimension African AmericanWhite P Worry. 41.22.001 Respect.44.25.001 Foolish. 09. 06.013 Expenses. 23. 12.001 Explain.14.09.003 Feelings.43.25.001 Operations. 34.18.001 Health problems. 12. 06.001 Younger Doctors. 27.12.001 Aging as Disease. 21.12.001

52. Limitations of the second study One patient-physician dyad had only 30 patients and 2 physicians

53. Future Study Effects of continuity of care (having SAME physician) in addition to the issue of patient-physician racial concordance. Age of the African American physicians becomes a pertinent issue as they retire or die. Increase in international medical graduates giving care to African Americans.

54. Attrition in the PHSE sample

55. Status of MD patient Matches: Total survivors Subjects naming doctor Pct Subjects with named doctor Pct Ss whose doctor has NCMB data Pct Ss doctors licensed by NCMB 4,1623,40981.9%96.2%98.0% 3,5592,55971.9%98.0%96.6% 2,8392,15375.8%95.2%98.8% 1,6391,41086.0%96.6%95.3%

56. Ethnicity of elders’ physicians– numbers are sizable

57. Ethnicity of elders’ physicians– percentages are stable

58. Slight trend toward diversity in physician-patient ethnic matching Year Percent of Whites with White MD Pct of African- Americans with African American MD Pct of Whites with Asian MD Pct of African- Americans with Asian MD 1986 (n=3272) 94.6%44.7%3.5%6.3% 1990 (n=2430) 93.1%39.3%4.7%9.0% 1994 (n=2017) 93.9%37.5%4.8%8.7% 1998 (n=1216) 91.3%38.2%7.2%8.0%

59. Transitions from 1986-90: numbers

60. Transitions from 1986-90: percentages

61. Next Steps Can the sample sizes of each sample sustain multi- variable analyses? How can we disentangle specific effects of individual provider continuity from broader effects of racial concordance between physicians and patients. Need more detailed statistics continuity of specific physicians and patients by racial dyad type.