1. Differences in the Quality of the Patient- Physician Relationship Among Terminally Ill African American and White Patients: Impact on Advance Care Planning and Goals of Care Alexander K. Smith, MD, MS, Roger B. Davis, ScD, Eric L. Krakauer, MD, PhD Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA Division of Palliative Care, Massachusetts General Hospital, Boston, MA

2. Previous Disparities Research African Americans, compared to Whites: –greater preference for life-sustaining treatment –less likely to have living will or HCP –report lower quality interactions with their physicians Impact of relationship quality on care: may be magnified in terminal illness

3. Aims To compare the quality of the patient- physician relationship between terminally ill African-American and White patients To examine the extent to which quality of the relationship contributes to differences between African Americans and Whites in advance care planning and goals of care

4. Study sample In-person surveys: Commonwealth Cummings study 803 African American and White patients Physician estimated survival of ≤ 6 months Referred from randomly selected physicians: 5 metropolitan areas, 1 rural county Response rate 87% 1996-1997

5. Patient-Physician Relationship Measures 6 patient reported patient-physician relationship quality measures (4 point scale, dichotomized at strongly agree vs. other responses): –Trust in physician –Feels respected by physician –Physician skilled in breaking bad news –Physician skilled at listening –Physician shares decision making –Physician helps navigate the medical system

6. Advance Care Planning and Goals of Care Presence of an advance care plan (any of following) –Living will –Health care proxy –Talked with family about plans for EOL care –Talked with physician about plans for EOL care Goal of “prolong life however possible”

7. Statistical Analysis Predictor: African American vs. White Estimated relative risks using Poisson regression with robust error variances Sequential models: –Unadjusted –Adjusted for age, gender, education, primary disease, and recruitment site –Adjusted for age, gender, education, primary disease, recruitment site, and all measures of the quality of the patient-physician relationship

8. Sample Characteristics African American (n=115) White (n=688) Age < 6552%42% Female Sex, %66%51% Income <$15,00063%31% Less than high school graduate55%26% Primary Disease Cancer48%54% Heart Disease14%18% COPD5%13% Renal Disease13%1% Other20%15%

9. Patient Reported Quality of the Patient- Physician Relationship, Terminally Ill African Americans Compared to Whites * * ** * * p<.05; trust in physician, p=.08

10. Goals and Advance Care Planning,, Terminally Ill African Americans Compared to Whites * * * p<.05

11. Goals and Advance Care Planning,, Terminally Ill African Americans Compared to Whites * * * * p<.05

12. Relative Risk of Having an Advance Care Plan African Americans Compared to Whites 0.20.61.0 Unadjusted Adjusted for age, sex, education, primary disease, and recruitment site Adjusted for age, sex, education, primary disease, recruitment site, and all measures of the quality of the patient-physician relationship Relative Risk (Reference group is Whites, RR=1.0)

13. Relative Risk of a Goal of “Prolong Life However Possible” African Americans Compared to Whites 1.02.03.04.0 0 Unadjusted Adjusted for age, sex, education, primary disease, and recruitment site Adjusted for age, sex, education, primary disease, recruitment site, and all measures of the quality of the patient-physician relationship Relative Risk (Reference group is Whites, RR=1.0)

14. Summary Among this terminally ill sample of patients –compared to Whites, African Americans gave lower ratings of the quality of the patient-physician relationship –While 80% of Whites had an advance care plan, less than half of the African Americans had an advanced care plan. –Patient reported quality of the patient-physician relationship did not explain differences in advance care planning and goals of care between African- Americans and Whites.

15. Limitations Data from 1996-1997 Single measure of race/ethnicity Physicians may have referred patients with strong relationships Cross sectional study

16. Conclusions/Implications Physicians referred patients prognosis ≤ 6 months, yet only 25% of physicians talked with patients about plans for EOL care In the context of low overall discussion rate, quality of the patient-physician relationship had no impact on differences in advance care planning and goals of care

17. Conclusions/Implications Focus: improving physician relationships with African American patients Future research should search for other potential mediating factors: –Values –Cultural beliefs –Health literacy –Attitudes toward the health care system –Treatment by the health care system

18. Thank you