Assessing the Role of the Physician and Practice Setting in Child Health Disparities

1. Assessing the Role of the Physician and Practice Setting in Child Health Disparities Lauren A. Smith1, Andrew Johnson2, Carol J. Simon2 1Boston University School of Medicine 2Abt Associates and Boston University School of Public Health Supported by grants from Agency for Healthcare Research and Quality, The California Endowment & The Commonwealth Fund

2. 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

3. 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 2007 • 65% response rate • Practice questions plus clinical vignettes

4. 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

5. Race/Ethnicity Variation in Vignettes

6. 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.

7. Vignette 1 Results by Race

8. Vignette 1 Results by Practice/Patient Characteristics

9. Vignette 1 Results by Practice/Patient Characteristics

10. 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.

11. Vignette 2 Results by Race

12. Vignette 2 Results by Practice/Patient Characteristics

13. Vignette 2 Results by Practice/Patient Characteristics

14. 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

15. 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