Kevin Fiscella

Disparities in Health Care by Race, Ethnicity, and Language Among the Insured:Findings From a National Sample

Background: Racial and ethnic disparities in health care have been well documented, but poorly explained. Objective: To examine the effect of access barriers, including English fluency, on racial and ethnic disparities in health care. Research Design: Cross-sectional analysis of the Community Tracking Survey (1996–1997). Subjects: Adults 18 to 64 years with private or Medicaid health insurance. Measures: Independent variables included race, ethnicity, and English fluency. Dependent variables included having had a physician or mental health visit, influenza vaccination, or mammogram during the past year. Results: The health care use pattern for English-speaking Hispanic patients was not significantly different than for non-Hispanic white patients in the crude or multivariate models. In contrast, Spanish-speaking Hispanic patients were significantly less likely than non-Hispanic white patients to have had a physician visit (RR, 0.77; 95% CI, 0.72–0.83), mental health visit (RR, 0.50; 95% CI, 0.32–0.76), or influenza vaccination (RR, 0.30; 95% CI, 0.15–0.52). After adjustment for predisposing, need, and enabling factors, Spanish-speaking Hispanic patients showed significantly lower use than non-Hispanic white patients across all four measures. Black patients had a significantly lower crude relative risk of having received an influenza vaccination (RR, 0.73; 95% CI, 0.58–0.87). Adjustment for additional factors had little impact on this effect, but resulted in black patients being significantly less likely than non-Hispanic white patients to have had a visit with a mental health professional (RR, 0.46; 95% CI, 0.37–0.55). Conclusions: Among insured nonelderly adults, there are appreciable disparities in health-care use by race and Hispanic ethnicity. Ethnic disparities in care are largely explained by differences in English fluency, but racial disparities in care are not explained by commonly used access factors.

Sociodemographics, self-rated health, and mortality in the US.

Using data from the 1987 National Medical Expenditure Survey, a representative sample of US civilians, and their 5-year mortality, we examined the adjusted relationships among baseline self-reported health, derived from SF-20 subscales (health perceptions, physical function, role function and mental health) and sociodemographics (age, sex, race/ethnicity, income and education) and subsequent mortality. Included were 21,363 persons aged 21 and over, with complete follow-up on 19,812. Physical function showed the greatest decline with age, whereas mental health increased slightly. Women reported lower health for all scales except role function. Greater income was associated with better health, least marked for mental health. Greater education was associated with better health, most marked for health perceptions. Compared with whites, blacks reported lower health, whereas Latinos reported higher health. Lower self-reported health predicted increased adjusted mortality. After adjustment for baseline self-rated health, the relationships between income and education and mortality were greatly attenuated, whereas the relationships between age, gender, race/ethnicity and mortality were not. Self-rated health exhibited more profound relationships with mortality in younger persons, those with more education, and whites. In conclusion, lower socioeconomic status (SES), and being black are associated with lower reported health status and higher mortality; women report lower health status but exhibit lower mortality; and Latinos report higher health status and exhibit lower mortality. The effects of SES on mortality are largely explained by their associations with self-rated health, whereas, the effects of gender and race/ethnicity on mortality appear to act through independent pathways. Because of these differential sociodemographic relationships caution is urged when using self-rated health measures in research, clinical, and policy settings.

Poverty or income inequality as predictor of mortality: longitudinal cohort study

Abstract Objective: To determine the effect of inequality in income between communities independent of household income on individual all cause mortality in the United States. Design: Longitudinal cohort study. Subjects: A nationally representative sample of 14 407 people aged 25-74 years in the United States from the first national health and nutrition examination survey. Setting: Subjects were followed from initial interview in 1971-5 until 1987. Complete follow up information was available for 92.2% of the sample. Main outcome measures: Relation between both household income and income inequality in community of residence and individual all cause mortality at follow up was examined with Cox proportional hazards survival analysis. Results: Community income inequality showed a significant association with subsequent community mortality, and with individual mortality after adjustment for age, sex, and mean income in the community of residence. After adjustment for individual household income, however, the association with mortality was lost. Conclusions: In this nationally representative American sample, family income, but not community income inequality, independently predicts mortality. Previously reported ecological associations between income inequality and mortality may reflect confounding between individual family income and mortality. Key messages Ecological studies have documented a powerful relation between national, state, or community indices of inequality and mortality at the population level These studies have not adequately controlled for confounding by family income measured at the individual level This study, using data from a nationally representative sample from the United States, showed no relation between community income inequality and mortality after adjustment for family income Poverty, not community income inequality, determines subsequent mortality; further study is needed to determine whether these findings apply to national or state-wide income inequality

Patient trust: Is it related to patient-centered behavior of primary care physicians?

Background:Patients’ trust in their health care providers may affect their satisfaction and health outcomes. Despite the potential importance of trust, there are few studies of its correlates using objective measures of physician behavior during encounters with patients. Methods:We assessed physician behavior and length of visit using audio tapes of encounters of 2 unannounced standardized patients (SPs) with 100 community-based primary care physicians participating in a large managed care organization. Physician behavior was assessed via 3 components of the Measure of Patient-Centered Communication (MPCC) scale. The Primary Care Assessment Survey (PCAS) trust subscale was administered to 50 patients from each physicians practice and to SPs. We used multilevel modeling to examine the associations between physicians’ Patient-Centered Communication during the SP visits and ratings of trust by both patients and SPs. Results:Component 1 of the MPCC, which explored the patients experience of the disease and illness, was independently associated with patients rating of trust in their physician. A 1 SD increase in this score was associated with 0.08 SD increase in trust (95% confidence interval 0.02–0.14). Each additional minute spent in SP visits was also independently associated with 0.01 SD increase in patient trust. (95% confidence interval 0.0001–0.02). Component 1 and visit length were also positively associated with SP trust ratings. Conclusions:Physician verbal behavior during an SP encounter is associated with trust reported by SPs and patients. Research is needed to determine whether interventions designed to enhance physicians’ exploration patients’ experiences of disease and illness improves trust.

Does prenatal care improve birth outcomes? A critical review

Objective To evaluate evidence that prenatal care improves birth outcomes. Data Sources The MEDLINE data base was searched for appropriate studies for the years 1966-1994; a review of published studies was also conducted. Methods of Study Selection Published observational and experimental studies of prenatal care that met specified criteria were selected. Data Extraction and Synthesis Studies were graded based on the system used by the United States Preventive Services Task Force. Data were assessed using established criteria for the evaluation of prenatal interventions: temporal relationship, biologic plausibility, consistency, alternative explanations, dose-response, strength of association, and cessation effects. Current evidence did not satisfy the criteria. Conclusion Prenatal care has not been demonstrated to improve birth outcomes conclusively. However, policymakers deciding on funding for prenatal care must consider these findings in the context of prenatal cares overall benefits and potential cost-effectiveness. Cost-effective reductions in low birth weight deliveries may be beyond the statistical powers of detection of current studies.

Patient-Centered Communication and Diagnostic Testing

PURPOSE Although patient-centered communication is associated with improved health and patient trust, information about the impact of patient-centered communication on health care costs is limited. We studied the relationship between patient-centered communication and diagnostic testing expenditures. METHODS We undertook an observational cross-sectional study using covert standardized patient visits to study physician interaction style and its relationship to diagnostic testing costs. Participants were 100 primary care physicians in the Rochester, NY, area participating in a large managed care organization (MCO). Audio recordings of 2 standardized patient encounters for each physician were rated using the Measure of Patient-Centered Communication (MPCC). Standardized diagnostic testing and other expenditures, adjusted for patient demographics and case-mix, were derived from the MCO claims database. Analyses were adjusted for demographics and standardized patient detection. RESULTS Compared with other physicians, those who had MPCC scores in the lowest tercile had greater standardized diagnostic testing expenditures (11.0% higher, 95% confidence interval [CI], 4.5%–17.8%) and greater total standardized expenditures (3.5% higher, 95% CI, 1.0%–6.1%). Whereas lower MPCC scores were associated with shorter visits, adjustment for visit length and standardized patient detection did not affect the relationship with expenditures. Total (testing, ambulatory and hospital care) expenditures were also greater for physicians who had lower MPCC scores, an effect primarily associated with the effect on testing expenditures. CONCLUSIONS Patient-centered communication is associated with fewer diagnostic testing expenditures but also with increased visit length. Because costs and visit length may affect physicians’ and health systems’ willingness to endorse and practice a patient-centered approach, these results should be confirmed in future randomized trials.

Health Disparities Based on Socioeconomic Inequities: Implications for Urban Health Care

Health is unevenly distributed across socioeconomic status. Persons of lower income, education, or occupational status experience worse health and die earlier than do their better-off counterparts. This article discusses these disparities in the context of urban medical practice. The article begins with a discussion of the complex relationship among socioeconomic status, race, and health in the United States. It highlights the effects of institutional, individual, and internalized racism on the health of African Americans, including the insidious consequences of residential segregation and concentrated poverty. Next, the article reviews health disparities based on socioeconomic status across the life cycle, beginning in fetal health and ending with disparities among the elderly. Potential explanations for these socioeconomic-based disparities are addressed, including reverse causality (e.g., being poor causes lower socioeconomic status) and confounding by genetic factors. The article underscores social causation as the primary explanation for health disparities and highlights the cumulative effects of social disadvantage across stages of the life cycle and across environments (e.g., fetal, family, educational, occupational, and neighborhood). The article concludes with a discussion of the implications of health disparities for the practice of urban medicine, including the role that concentration of disadvantage plays among patients and practice sites and the need for quality improvement to mitigate these disparities.

National Cancer Institute Patient Navigation Research Program: methods, protocol, and measures.

Patient, provider, and systems barriers contribute to delays in cancer care, a lower quality of care, and poorer outcomes in vulnerable populations, including low‐income, underinsured, and racial/ethnic minority populations. Patient navigation is emerging as an intervention to address this problem, but navigation requires a clear definition and a rigorous testing of its effectiveness. Pilot programs have provided some evidence of benefit, but have been limited by evaluation of single‐site interventions and varying definitions of navigation. To overcome these limitations, a 9‐site National Cancer Institute Patient Navigation Research Program (PNRP) was initiated.

Validity of the Patient Health Questionnaire 2 (PHQ-2) in Identifying Major Depression in Older People

OBJECTIVES: To determine the performance of the Patient Health Questionnaire 2 (PHQ‐2) against the criterion standard for diagnosing major depression, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV), and to examine its performance across age, sex, and racial/ethnic groups.

Low-dose mifepristone for uterine leiomyomata.

OBJECTIVE To compare the effect of 5 and 10 mg of mifepristone on uterine leiomyoma size and symptoms, and to measure side effects. METHODS Forty premenopausal women with large, symptomatic leiomyomata were randomized to receive either 5 or 10 mg of mifepristone daily for 6 months in an open-label study. Uterine volume was measured at bimonthly intervals by sonography. Serum concentrations of hemoglobin levels, follicle-stimulating hormone, and liver enzymes were obtained, and endometrial samples, symptoms, and menstrual bleeding were also assessed. RESULTS Nineteen of 20 subjects taking 5 mg and all 20 subjects taking 10 mg completed all 6 months of the study. Mean uterine volume shrank by 48% (P < .001) in the 5-mg group and 49% (P < .001) in the 10-mg group, a nonsignificant difference. Leiomyoma-related symptoms were comparably reduced in both groups. Amenorrhea occurred in 60–65% of both groups. Hemoglobin levels increased by 2.5 g/dL in anemic subjects. The incidence of hot flashes increased significantly over baseline in the 10-mg group but not in the 5-mg group. Simple endometrial hyperplasia occurred in 28% of all subjects, with no difference between groups. No atypical hyperplasia was noted. CONCLUSION Mifepristone in doses of 5 mg or 10 mg results in comparable leiomyoma regression, improvement in symptoms, and few side effects. Further study is needed to assess the long-term safety and efficacy of low-dose mifepristone.