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Overcoming Healthcare Disparities: The Role of Patient-Centered Care

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  1. Overcoming Healthcare Disparities:The Role of Patient-Centered Care Lisa A. Cooper, MD, MPH Professor of Medicine, Epidemiology, and Health Policy and Management Johns Hopkins Medical Institutions

  2. Racial and ethnic disparities in health are documented • Life expectancy at birth – Blacks vs. Whites,10 year gap for men, 5 year gap for women • Infant mortality rate – Blacks and Native Americans vs. Whites: twice as high • Death rate – Blacks vs. whites: greater for cancer, diabetes, heart disease, HIV/AIDS, homicide; Hispanics vs. Whites: greater for diabetes • Morbidity – most ethnic minorities vs. Whites: higher for cancer, diabetes, hypertension, obesity, HIV/AIDS, tuberculosis, hepatitis

  3. Potential Reasons for Disparities in Health • Biologic factors • Socioeconomic status • Environmental factors • Discrimination/Stress • Cultural factors • Health risk behavior • Access to healthcare • Quality of healthcare Race Health

  4. Access to Health Care for Racial and Ethnic Groups Modified From Access to Health Care in America (1993, Millman M, ed). Cooper LA, Hill MN, and Powe NR. JGIM 2002; 477-486

  5. Unequal Treatment: A Report of the Institute of Medicine* Difference Clinical Appropriateness and Need, Patient Preferences Systems, Legal, Regulatory Quality of Care Disparity Discrimination, Bias, Clinical uncertainty *National Academy Press, Washington DC, 2003

  6. Racial and ethnic healthcare disparities are pervasive • Conditions: cancer, diabetes, heart disease, kidney disease, HIV/AIDS, mental health, respiratory diseases (e.g., asthma) • Populations: young, old, urban, rural, men, women, immigrants, non-immigrants • Settings: primary care, emergency care, hospital care, specialty care, nursing homes • Levels and types of care: preventive, acute care, chronic disease management • Dimensions of healthcare quality: timeliness, effectiveness, safety, patient-centeredness

  7. Dimensions of Health Care Quality • Structure: “characteristics of the settings in which care is delivered…” • Process: “ …the care itself, or activities undertaken by the health care system…” • Outcome: “the effect of care on the health and welfare of individuals or populations…” Donabedian A. JAMA 1988;260:1743-1748

  8. Process interpersonal, technical care, or appropriateness of care Outcome Structure race concordance, staff expertise, availability, organization, coordination, patient ratings of care, equity of services death, complications Examples of Structure, Process, and Outcome Variables

  9. Disparities in Process of Care • Technical care – many studies • Ethnic minorities receive fewer preventive services, diagnostic and therapeutic tests and procedures, and fewer appropriate medications • Patient-centered or interpersonal care – fewer studies • Ethnic minority patients rate interpersonal care from physicians more negatively than whites • It is unclear whether this is due to ethnic/racial discordance, poor communication, bias, or mistrust • Few disparities studies make links between structure, processes, and outcomes

  10. Process Interpersonal or Patient-centered Care Outcome Structure Patient ratings of PDM Race Concordance * physicians’ participatory decision-making style

  11. Concordance • What is it? • a structural dimension of health care quality • shared identities between patients and health professionals • Why do we care? • Because most ethnic minorities see physicians who differ from them in key social characteristics • Patients and physicians may be concordant in: • Visible demographic factors such as race/ethnicity, gender, age, education, social class, language • Less visible factors such as beliefs, values, expectations, preferred roles

  12. Patient-centered Care “Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions…” *Institute of Medicine, “Crossing the Quality Chasm, 2001

  13. Race, Gender, and Partnership in the Patient-Physician Relationship • Design: Cross-sectional telephone survey • Subjects: 1816 adults (784 W, 814 AA, 218 Other) who had seen their MD (n=65) within the past 2 weeks • Setting: 32 primary care practices, large network style managed care organization in Washington D.C. area • Predictor variables: race and gender concordant or discordant status in patient-physician relationship • Main Outcome: patients’ ratings of their MD’s participatory decision-making (PDM) style Cooper-Patrick L et al, JAMA 1999;282:583-589

  14. Measurement of Physicians’ Participatory Decision-Making Style* Patient is asked: • If there were a choice between treatments, how often would this doctor ask you to help make the decision? • How often does this doctor make an effort to give you some control over your treatment? • How often does this doctor ask you to take some of the responsibility for your treatment? *Kaplan SH et al, Medical Care 1995;33:1176-1187 Each item contributes 33.3 points. Maximum score is 100 points.

  15. Ethnic minorities rate their visits with physicians as less participatory P=0.007 P=0.05 PDM scores range from 0-100. A higher score means visit is more participatory. Cooper-Patrick L , JAMA 1999;282:583-589

  16. Patients in race-concordant relationships rate their physicians as more participatory P-value NS P=0.02 Mean PDM Style Score Adjusted for patients’ age, gender, education, marital status, health status, length of the patient-physician relationship, physician gender (race concordant analysis) and physician race (gender concordance analysis). Cooper-Patrick L, JAMA 1999;282:583-589

  17. Process Interpersonal or Patient-centered Care: Communication Outcome Structure Patient ratings of PDM* and Satisfaction Race Concordance * physicians’ participatory decision-making style

  18. Patient-physician communication is related to important outcomes • Patient adherence • Patient satisfaction • Clinical outcomes • Glycemic control • BP control • Pain reduction • Depression resolution Roter 1988, Greenfield 1988, Kaplan 1989, Stewart 1995, Kaplan 1995

  19. Patient-Centered Communication, Ratings of Care and Concordance of Patient and Physician Race • Design: cross-sectional study using pre-visit and post‑visit surveys and audiotape analysis • Participants: 458 African American and white adult patients receiving care from 61 PCPs • Setting: urban primary care practices serving managed care and fee-for-service patients • Patient recruitment: ~10 patients per MD recruited consecutively from waiting rooms Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Ann Intern Med 2003;139:907-915

  20. Functions of Clinical Communication • Data-gathering • Educating and counseling patients • Relationship-building • Partnering with patients to negotiate diagnostic and treatment decisions Lipkin, Putnam, & Lazare, 1995

  21. Content (questions and information-giving) Biomedical talk Psychosocial talk Affect Emotional Talk - Negative talk Positive talk - Social talk Process Orientation (directions or instructions) Facilitation (includes partnership-building) Measuring Clinical Communication* *Roter Interaction Analysis System (RIAS) Roter D, Larson S. Patient Educ Couns 2002;46:243-51

  22. Examples from RIASCommunication Categories • Biomedical talk “Your blood pressure is 100 over 70.” “I was in the hospital last year for ulcers.” • Psychosocial talk “You really need to get out and meet more people.” “I guess every marriage has its ups and downs.” • Emotional talk “This must be very hard for you.” “I hope you’ll be feeling better soon.” • Partnership-building “Do you follow me?” “How does that sound to you?”

  23. Measuring Emotional Tone of Visits using the RIAS Coders are asked to rate overall emotional tone of the visit for patients and physicians: • Physician positive affect = (assertiveness + interest + responsiveness + empathy) - hurried • Patient positive affect = (assertiveness + interest + friendliness + responsiveness + empathy)

  24. The Patient-CenteredClinical Interview • Visit duration is longer • Speech speed is lower • Physicians are less verbally dominant • doctor talk to patient talk ratio is close to 1 • Patient-centeredness ratio is high: more psychosocial, emotional, and partnership talk than biomedical talk • More positive emotional tone

  25. Physicians communicate differently with black and white patients Adjusted for: patient age, gender, education level, and self-rated health status; and physician gender, race, time since completing training, and report of how well he/she knows each patient. *p-value from linear regression with GEE.** Patient and physician affect scores are derived from audiotape coders’ impressions of the overall emotional tone of the medical visit. Johnson RL, Roter DL, Powe NR, Cooper LA. Am J Public Health 2004;94:2084-2090.

  26. Race-concordant visits are longer with slower speech and more positive patient emotional tone P=0.05 P=0.01 P=0.03 P=0.19 Adjusted for patient age, race, gender, and health status, physician gender & yrs in practice Cooper LA et al, Ann Intern Med 2003;139:907-915

  27. Patients in Race-Concordant Relationships Rate Their Physicians Better P=.01 P<.01 P=.03 Mean Score/Probability Analyses adjusted for patient gender, race, age, and health status, physician gender, years in practice, and patient-centered communication. Cooper LA et al, Ann Intern Med 2003;139:907-915

  28. Summary • African American patients experience visits in which physicians are less patient-centered • African Americans in race-discordant relationships with their physicians experience: • Lower levels of satisfaction • Less participation in medical decisions • Shorter visits with less positive emotional tone • Differences in communication do not explain why patients in race-discordant relationships rate their care worse • Other factors, such as physician and patient attitudes, may play a role

  29. Process Interpersonal Care: Bias Outcome Structure Patient ratings of care Race Concordance

  30. Explicit vs. Implicit Bias • Explicit (conscious) bias: attitudes and beliefs we recognize and know we have • Implicit (unconscious) bias: attitudes that are unavailable to introspection and outside of conscious cognition • Can unintentionally affect behavior • Are better predictors of behavior than self reported measures of prejudice, stereotyping and discrimination

  31. Clinician Racial Bias, Communication Behaviors and Patient Experiences of Care • Design: Cross-sectional study • Participants: 39 primary care clinicians and 213 of their African American patients • Setting: 24 urban, community-based primary care practices in Baltimore, Maryland and Wilmington, Delaware • Main predictor variables: Clinicians’ implicit attitudes about race (race attitude IAT and patient race/medical compliance IAT)

  32. The Race Implicit Association Test(http://www.implicit.harvard.edu) • An indirect measure of an individual’s implicit (unconscious) attitudes • Images appear rapidly on computer screen and subjects respond by sorting pairs of images and attributes using right and left keys • Premise: individuals will respond faster to concepts that are strongly associated compared to those that have weak associations • If subjects match white+good/black+bad pairings faster than black+good/white+bad pairings, then the race IAT score differs from zero and is positive – labeled implicit white preference Greenwald, McGhee, Schwartz, 1998

  33. African American European American & unpleasant pleasant & pain death stink grief agony filth tragedy vomit gentle happy smile joy warmth pleasure paradise rainbow Implicit preference for whites: Response to these pairings is faster…

  34. African American European American & unpleasant pleasant & pain death stink grief agony filth tragedy vomit gentle happy smile joy warmth pleasure paradise rainbow …than response to these pairings

  35. African American European American & & willing cooperative compliant reliable adherent helpful doubting reluctant hesitant apathetic resistant lax Implicit association for European American and compliant patient Response to these pairings is faster… Compliant Patient ReluctantPatient

  36. African American European American & & doubting reluctant hesitant apathetic resistant lax …than response to these pairings Compliant Patient ReluctantPatient willing cooperative compliant reliable adherent helpful

  37. Methods, continued • Main outcomes: • Audiotaped Measures: Clinician and patient communication behaviors measured by Roter Interaction Analysis System (RIAS) • Patient ratings of care: overall satisfaction, trust in clinician, participation in decision-making, and quality of interpersonal care measured by post-visit survey • Analysis: determine whether clinicians’ implicit attitudes predict differences in communication and patient ratings of care* *Linear and logistic regression with generalized estimating equations to account for clustering of patients by clinician

  38. Content (questions and information-giving) Biomedical talk Psychosocial talk Affect Emotional Talk - Negative talk Positive talk - Social talk Process Orientation (directions or instructions) Facilitation (includes partnership-building) Measuring Clinical Communication* *Roter Interaction Analysis System (RIAS) Roter D, Larson S. Patient Educ Couns 2002;46:243-51

  39. Audiotape Ratings of Clinicianand Patient Emotional Tone • Clinician behaviors • Positive affect – average of 6 items each rated on a 5-point scale: interest, warmth, engagement, respect, and sympathy • Negative affect – average of 2 items each rated on a 5-point scale: dominance and hurried/rushed • Patient behaviors • Positive affect – average of 5 items each rated on a 5-point scale: interest, warmth, engagement, sympathy, and respect

  40. Patient Ratings of Clinician • Overall satisfaction • Overall, I was satisfied with this visit • I would recommend this provider to a friend • Quality of interpersonal care • My provider has a great deal of respect for me • My provider likes me • I like this provider • Participation in decision-making • If there were a choice, this provider would ask me to help make the decision • Trust in provider • I trust this provider to act in my best interests Responses are on 5-point Likert scale from strongly agree to strongly disagree.

  41. Interpersonal CareQuality Measures • Patient-centeredness ratio is high: more psychosocial, emotional, and partnership talk than biomedical and procedural talk • Clinicians and patients exhibit more positive emotional tone and less negative emotional tone • Patients report higher levels of trust, respect, and satisfaction, and participation in decision-making

  42. Characteristics of Clinicians

  43. Characteristics of Patients

  44. Percent of respondents with each score Strong preference for Whites 14% Moderate preference for Whites 26% Slight preference for Whites 26% Little to no preference 10% Slight preference for Blacks 14% Moderate preference for Blacks 5% Strong preference for Blacks 5% Clinician Responses to IAT(N=39) 66% The IAT D (difference score)ranges from -2 to +2, with 0 indicating no relative preference for blacks compared to whites, and positive scores indicating some degree of implicit bias favoring Whites. [mean score for this sample is +0.24 (.49)]

  45. Percent of Harvard website respondents with each score Strong preference for Whites 27% Moderate preference for Whites 27% Slight preference for Whites 16% Little to no preference 17% Slight preference for Blacks 6% Moderate preference for Blacks 4% Strong preference for Blacks 2% Implicit Preference for White vs. Black People by 732,881 respondents on Project Implicit websites, July 2000- May 2006 70%

  46. Association of Clinician Implicit Racial Bias withCommunication Behaviors The beta coefficient means for each 1-point increase in the IAT score --indicating more pro-white bias among clinicians – clinician’s negative affect was higher and African American patients’ positive affect was lower . Adjusted for patient age, education, health status, clinician’s gender, race, and the interaction of clinician race with implicit bias.

  47. Association of Clinician Race/Medical Compliance Bias with Communication Behaviors The beta coefficient means for each 1-point increase in the IAT score --indicating more pro-white bias among clinicians – the communication in the visit was less patient-centered. Adjusted for patient age, education, health status, clinician’s gender, race, and the interaction of clinician race with implicit bias.

  48. Clinician Racial Bias andPatient Reports of Care 0.63 I was satisfied with this visit 0.32 I would recommend this doctor to a friend 0.24 This doctor respects me 0.48 This doctor asks me to help decide my treatments 0.22 I like this doctor 0.47 I trust this doctor 0 0.5 1.0 1.5 2.0 4.0 6.0 8.0 10.0 Odds Ratio As the implicit bias score increases the patient has lower odds of strongly agreeing

  49. Clinician Race/ Medical Compliance Bias and Patient Reports of Care 0.49 I was satisfied with this visit 0.57 I would recommend this doctor to a friend 0.48 This doctor respects me 0.20 This doctor asks me to help decide about my treatments 0.89 I like this doctor 0.55 I trust this doctor 0 0.5 1.0 1.5 2.0 4.0 6.0 8.0 10.0 Odds Ratio As the implicit bias score increases the patient has lower odds of strongly agreeing