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RESEARCH AND PRACTICE |
Michelle van Ryn is with the Department of Family Practice and Community Health, University of Minnesota Medical School; the Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis; and the Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center. Diana Burgess and Joan Griffin are with the Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, and the Department of Medicine, University of Minnesota Medical School. Jennifer Malat is with the Department of Sociology, University of Cincinnati, Cincinnati, Ohio.
Correspondence: Requests for reprints should be sent to Michelle van Ryn, PhD, MPH, Department of Family Practice and Community Health, University of Minnesota, Room 225 Dinnaken Building, 925 Delaware St SE, Minneapolis, MN 55414 (e-mail: vanry001{at}umn.edu).
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ABSTRACT |
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Objectives. A growing body of evidence suggests that provider decisionmaking contributes to racial/ethnic disparities in care. We examined the factors mediating the relationship between patient race/ethnicity and provider recommendations for coronary artery bypass graft surgery.
Methods. Analyses were conducted with a data set that included medical record, angiogram, and provider survey data on postangiogram encounters with patients who were categorized as appropriate candidates for coronary artery bypass graft surgery.
Results. Race significantly influenced physician recommendations among male, but not female, patients. Physicians’ perceptions of patients’ education and physical activity preferences were significant predictors of their recommendations, independent of clinical factors, appropriateness, payer, and physician characteristics. Furthermore, these variables mediated the effects of patient race on provider recommendations.
Conclusions. Our findings point to the importance of research and intervention strategies addressing the ways in which providers’ beliefs about patients mediate disparities in treatment. In addition, they highlight the need for discourse and consensus development on the role of social factors in clinical decisionmaking.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The lack of evidence supporting other causal pathways has led to an increased focus on the role of provider behavior. As a result, there is a growing body of evidence suggesting that provider behavior and decisionmaking contribute significantly to racial/ethnic disparities in care9,25,29–37 (see van Ryn38 for a review). However, little is known about why patient race or ethnicity influences the clinical decisionmaking process, and thus, there is an inadequate evidence base for guiding intervention priorities and strategies.
One approach to understanding the processes by which patient race/ethnicity influences provider decisionmaking can be guided by the extensive amount of social psychological research demonstrating how unconscious stereotypes may lead to bias even among well-intentioned, egalitarian people.2,38–40 This evidence suggests that the effects of race/ethnicity on provider behavior may be mediated by unconscious stereotypes or beliefs. In other words, providers’ beliefs about patients may vary according to patients’ race/ethnicity, and these beliefs, in turn, may influence their behavior and decisionmaking.
We tested this hypothesis regarding predictors of physician recommendations using a data set that included medical record and provider survey data collected from coronary artery disease patients who had an angiogram performed at one of 8 New York hospitals. Understanding provider recommendations is essential for understanding disparities in care, given that previous published results from the present data set indicate that such recommendations are the proximal cause of almost all observed disparities in receipt of coronary artery bypass graft surgery (CABG).30
We examined the factors associated with provider recommendations for CABG among the subset of patients who were appropriate candidates for this procedure but not for other aggressive treatments. The data used in this study had unique advantages in that they included provider survey information on the postangiogram encounter at which a treatment determination was made. In their survey responses, providers reported on their recommendations and rated patients on a number of social and behavior characteristics. Previous analyses of the dataset used in the present study revealed that physicians’ perceptions of patients on these measures varied according to patient race, independent of patient age, gender, race, frailty/sickness, mental health status, mastery, and social assertiveness and physician characteristics. Specifically, physicians rated non-White patients as less likely than their White counterparts to participate in cardiac rehabilitation, to desire a physically active lifestyle, and to have a sufficient amount of social support and more likely to be non-adherent and to abuse drugs.39
In another report involving the present data, we found that patients who had already been rated either as appropriate candidates for CABG or as patients for whom CABG was necessary were more likely to undergo CABG if they had specific clinical characteristics (left main coronary artery disease, 3-vessel disease, and older age).30 This set of findings suggests the possibility that providers overapply certain clinical characteristics when making treatment recommendations. If these characteristics are also associated with patient race/ethnicity, they may mediate a portion of the observed effect of patient race/ethnicity on provider recommendations. The present data provided an opportunity for a meaningful examination, after control for physician characteristics, patient clinical characteristics, and insurance status, of the degree to which perceptions of patients mediate the observed relationship between patient race/ethnicity and provider recommendations for CABG among patients who are appropriate candidates for the procedure.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Of the 1261 patients who were classified as appropriate candidates for CABG but not for PTCA, an alternate revascularization procedure, a random sample of 614 were recruited for the survey portion of the study. Those patients who also were appropriate candidates for PTCA were eliminated from the analyses to provide a reasonable and conservative test of physician recommendations for CABG. In the case of each of the 614 patients who were appropriate for CABG, the physician (or physicians) identified as involved in the treatment decision by the hospital, patient, or another physician was sent a self-administered survey focusing on the postangiogram encounter in which the treatment determination was discussed. Of the 792 encounters identified as relevant to the 614 patients, physicians returned surveys with data on 570 (72%) postangiogram encounters among 462 (75%) patients.
Physicians’ likelihood of response was unrelated to the race/ethnicity of the patient. Of the 570 encounters with patients who were appropriate candidates for aggressive treatment, 38 involved patients who were found to have had previous CABG surgery and thus were eliminated from the analyses, resulting in 532 physician reports on encounters. As a result, 532 encounters were included in the present analyses. Of these encounters, 305 involved male patients (57%) and 227 involved female patients (43%). Only encounters with White (n = 182; 34%), Black (n = 161; 30%), and Hispanic (n = 189; 36%) patients were sampled for this study.
Measures
Dependent variable.
The dependent variable was whether or not the physician reported recommending CABG. Physicians were asked "How strongly did you recommend CABG/PTCA for this patient?" Response options were exclusively as only appropriate treatment (1), best of the options (2), neutrally as one possible treatment (3), and recommended against CABG (4). A dichotomous dependent variable was created in which responses 1 and 2 were combined as "physician recommended CABG" (coded 1) and responses 3 and 4 were combined as "physician did not recommend CABG" (coded 0).
Independent variables. Data on patient race/ethnicity and gender were obtained from medical records. We chose to use medical record data rather than patient self-reports because our hypotheses focused on the effect of providers’ perceptions regarding patients’ race/ethnicity.
We used 4 categories of potential mediators of the effects of patient race/ethnicity on physicians’ recommendations for CABG. Each category, or block of variables, is described subsequently.
One hypothesis regarding the reasons for racial/ethnic disparities in physician recommendations is that non-White patients see different physicians than White patients, and these physicians are less likely to recommend CABG. The physician characteristics we examined included age, race/ethnicity, specialty (cardiologist vs other), gender, and whether the physician was an attending physician or a trainee (resident or fellow). All physician characteristics were assessed through self-reports provided on the self-administered physician survey.
Information on clinical factors shown to influence receipt of CABG independent of appropriateness for CABG was obtained through abstraction of medical record data. These factors included patient age as well as the presence of disease of the left main coronary artery (left main disease) and of disease in 3 coronary arteries (3-vessel disease).
Data on patients’ health insurance coverage were abstracted from medical records. Insurance status was transformed into a dichotomous variable in which patients who had Medicare or private health insurance coverage were compared with those who did not (i.e., were solely insured by Medicaid or had no insurance).
In terms of physicians’ perceptions of patients’ social and behavioral characteristics, the following explanation was used to ask physicians to rate patients on a set of 24 characteristics:
Many studies have found certain patient characteristics to be associated with compliance with treatment regimens and following medical advice. As part of this study, we will be attempting to predict compliance and treatment outcomes on the basis of patient characteristics. We would like to ask you a few questions about your impressions of this patient. Although it is sometimes hard to get to know patients well in a short time, we have found that even the first or general impressions that physicians provide us with can be very helpful in predicting compliance. Please consider how this patient behaved in your interaction(s) with him/her.
Physicians’ perceptions of patients’ personality characteristics were assessed through ratings they made on semantic differential measures including (1) intelligent–unintelligent, (2) self-controlled–lacking self-control, (3) pleasant–unpleasant, (4) educated–uneducated, (5) rational–irrational, (6) independent–dependent, and (7) responsible–irresponsible. For each item, ratings ranged from 1 (e.g., intelligent) to 7 (e.g., unintelligent).
Physicians’ perceptions of patients’ probable behavior and social role were assessed through asking physicians their opinion on how likely the patient was to lack social support; overreport (exaggerate) discomfort; fail to comply with medical advice; abuse drugs, including alcohol; strongly desire a very physically active lifestyle; participate in cardiac rehabilitation (if prescribed); attempt to manipulate physicians; initiate a malpractice suit; have major responsibility for the care of a family member (or family members); and have significant career demands/responsibilities. Response options ranged from not at all likely to extremely likely on a 5-point scale. Because most of these items yielded heavily skewed response distributions, we transformed each into a dichotomous variable using the median as the cut point.
Analysis Plan
The goal of the analyses described here was to examine the role of 4 classes of potential mediators of the observed relationship between patient race/ethnicity and physician recommendations for CABG among patients who were appropriate candidates for the procedure: (1) physician characteristics, (2) clinical characteristics shown to influence physician decisionmaking even in the case of patients classified as appropriate candidates for CABG, (3) patients’ insurance status, and (4) physicians’ perceptions of patients’ social and behavioral characteristics. We followed the steps described by Baron and Kenny45 and Judd and Kenny46 as necessary for establishing mediation. First, the overall effect of the independent variable on the dependent variable must be statistically significant. Second, the independent variable must have a significant effect on the mediator (or mediators). Third, the mediator (or mediators) must have a significant association with the dependent variable. Finally, to establish complete (vs partial) mediation, the entry of the mediator (or mediators) into the model must eliminate the impact of the independent variable on the dependent variable.
Our first step in assessing mediation was to examine the association between patient race/ethnicity and physician recommendations among patients who were classified as appropriate candidates for CABG according to the RAND criteria and to test for interaction effects with patient gender and non-White socially constructed race/ethnicity categories. Our second step was to examine each potential mediator for a significant association with patient race/ethnicity. In this series of bivariate analyses, we used the 
2 test of association in cases in which the dependent variable was nominal or ordinal, and we used comparison of mean scores and F tests for differences in means in the case of interval-level variables.
In our third step, we examined the relationship between the potential mediators and physician recommendations for CABG. Next, we explored the possibility that the observed effects of patient race/ethnicity on physician recommendations were due to the hypothesized mediator by examining the impact of the mediator on the association between patient race/ethnicity and physician recommendations.
Initially, we tested the mediating role of provider characteristics. We then examined the possibility that clinical characteristics were distributed differently according to patient race/ethnicity, along with the possibility that these clinical characteristics mediated the effects of race/ethnicity on provider recommendations. The importance of these analyses is highlighted by an earlier report showing that the presence of left main disease, 3-vessel disease, or both, increased patients’ likelihood of undergoing CABG, whether or not they were rated as either appropriate candidates for CABG or in need of the procedure.30 In other words, patients who were appropriate candidates for CABG but did not have left main artery disease or 3-vessel disease were less likely to undergo the appropriate treatment.
Next, we examined the effects of insurance coverage on the relationship between patient race/ethnicity and physician recommendation. Finally, we tested the degree to which physicians’ perceptions of patients mediated the effects of patient race/ethnicity on physician recommendations, independent of physician characteristics, clinical characteristics, and insurance status.
Each of the potential mediating variables that exhibited a significant bivariate association with both the independent variable (patient race/ethnicity) and the dependent variable (physician recommendations) was entered into a multivariate model in blocks corresponding to the 4 categories listed earlier: physician characteristics, clinical characteristics, insurance status, and physicians’ perceptions of patients. Initially, patient race/ethnicity was entered into a logistic regression equation, followed by physician characteristics, clinical variables, insurance status, and, finally, the social and behavioral factors. This strategy allowed us to examine whether a given block of variables attenuated the relationship between race/ethnicity and provider recommendations and thus, fulfilled the statistical requirements for mediation.
Individual variables that did not achieve statistical significance at a particular step were dropped from the equation at the subsequent step. Physicians’ perceptions of patients’ social and behavioral characteristics were entered in the final step to provide the most conservative test of these potential mediators.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Types of Providers Seen
Table 1
presents the results of tests assessing bivariate relationships among all of the potential mediators. Patients in all race/ethnicity categories were equally likely to be seen by an attending physician (vs a resident or fellow), a cardiologist, and a male physician; however, White patients saw, on average, older physicians than Blacks (among Blacks: mean = 43.13, SD= 7.18; among Whites: mean = 45.9, SD= 7.86; P < .01) and were less likely to see a non-White physician than their Black counterparts (Black patients, 30%; White patients, 9%; 21 = 28.26, P < .01). The fact that Blacks were more likely to see non-White physicians did not reflect race/ethnicity congruence among non-Whites, as only 1% of the physicians in the sample identified themselves as Black. The remainder were largely of ethnic backgrounds originating in Asia (India and bordering nations).
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Distribution of Clinical Characteristics
There were no significant racial/ethnic differences in rates of 3-vessel disease in this sample of male patients who were appropriate candidates for CABG according to the RAND criteria. Black patients were significantly younger than Whites (mean = 43 years vs mean = 46 years; P < .01) and had lower rates of left main disease (10% vs 19%; P < .06).
Role of insurance status as a mediator.
As can be seen in Table 1
, there were significant race/ethnicity differences in terms of insurance coverage. Only 3% of White patients’ medical records indicated that they had Medicaid coverage or no coverage, while 21% of Black patients had Medicaid or no coverage (P < .00).
Influence of insurance status on physician recommendations. Insurance status exhibited significant bivariate associations with physician recommendations. Only 26% of patients with Medicaid coverage or no insurance coverage received a recommendation for CABG, as opposed to 43% of patients with Medicare or private coverage (P < .01).
Mediating effect of race/ethnicity on provider recommendations for CABG.
As shown in Table 1, physicians rated Black patients significantly more negatively in terms of their likelihood of having sufficient social support, failing to comply with medical advice, abusing drugs, having significant career demands, and desiring a physically active lifestyle. Blacks were also rated as less likely than Whites to comply with medical advice or participate in cardiac rehabilitation if prescribed, although these differences were of only borderline statistical significance. Few Black patients were rated as more educated or intelligent than their White counterparts.
Table 2 provides the results of the multivariate analyses predicting provider recommendations for CABG among men who were rated as appropriate candidates for the procedure (n=199). Variables were entered in a series of 4 blocks to allow identification of the degree to which the 4 categories of various sets of predictors mediated the effects of race/ethnicity on provider recommendations (unadjusted Black–White odds ratio [OR]=0.40; P<.01).
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Third, the effect of insurance status on physician recommendations had, at best, a very small influence on the relationship between race and physician recommendations for CABG. Finally, of the measures of physicians’ perceptions of patients’ social and behavioral characteristics, only physician perception that the patient desired a physically active lifestyle and was educated had significant associations with recommendations. Most notably, the addition of these variables eliminated the effect of patient race/ethnicity on physician recommendations for CABG, providing support for the hypothesis that physicians’ perceptions of patients mediate the effects of patient race on their treatment recommendations.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The complex relationship between race/ethnicity and gender reinforces the need for researchers to focus on the complex and interconnected nature of the influence of socio-demographic variables on provider behavior. This idea is consistent with a great deal of social cognitive research showing that people tend to categorize others at the intermediate level of subtype (e.g., Black woman, elderly White man) rather than in terms of overarching categories of race and gender, the reason being that subtypes are more descriptive and consequently allow more precision and cognitive efficiency.47,48
Our study also provided support for the primary hypotheses regarding the central importance of the way patient race (as well as other nonclinical characteristics) influences providers’ conscious and unconscious beliefs about patients and how these beliefs in turn influence their decisionmaking. Specifically, disparities in coronary artery disease treatment were shown to be at least partially mediated by the ways in which patient race or ethnicity influenced physicians’ perceptions of patients’ social and behavioral characteristics. This finding adds to a small but growing body of evidence8,34,47–59 on how physicians often use patients’ demographic characteristics (e.g., race/ethnicity) as decisionmaking heuristics, including a very interesting line of research focusing on providers’ use of "base rates" (e.g., population statistics on prevalence of a characteristic in a subgroup) to inform their decisionmaking.55,60,61
The present findings are supported by the results of a number of other studies indicating that social and behavioral factors influence providers’ clinical decisionmaking, both explicitly (consciously) and implicitly (unconsciously). There is considerable empirical evidence that patients’ gender, age, socioeconomic status, diagnosis, marital status, sexual orientation, symptom severity, and race/ethnicity can influence providers’ beliefs about and expectations of patients independent of other factors.33,39,62–73 Furthermore, both randomized vignette studies and examinations of actual provider practices indicate that patients’ demographic characteristics influence clinical decisionmaking.8,34,51–59
Moreover, the fact that physicians’ perceptions of the degree to which patients were educated (P < .001) and desired a physically active lifestyle (P < .07) were independent predictors of physicians’ recommendations for CABG has important implications for understanding provider decisionmaking in general. Physicians’ exclusion of candidates for CABG on the basis of factors unrelated to accepted clinical guidelines may disproportionately exclude non-White patients. Although it is impossible to ascertain the accuracy of physicians’ ratings of patients’ desire for a physically active lifestyle, it is clear from a previous study39 that physicians underestimate Black patients’ education levels.
There are a number of initiatives aimed at ameliorating treatment disparities, including a variety of programs focused on increasing providers’ cultural competence. Evidence regarding the effectiveness of these approaches is not yet available, and, because most cultural competence programs focus on conscious beliefs rather than unconsciously activated stereotypes, it is unclear whether these programs will have an impact on the disparities reflected in these findings. However, research on unconscious bias and stereotyping suggests that current cultural competence programs that focus on improving interpersonal and communication skills, ability to elicit patient self-disclosure, active listening skills, and self-awareness are promising.
There is research evidence that, under certain conditions, individuals can consciously replace automatically activated stereotypes. These studies suggest that a provider is less likely to be influenced by a group stereotype if the provider (1) is aware of the potential for judgments, emotions, and behaviors to be biased; (2) is aware of a stereotype being activated; (3) is highly motivated to replace stereotypes with individual information; and (4) has sufficient cognitive resources (time and cognitive capacity) available for all of these cognitive tasks.
In conclusion, the present findings point to the importance of research and intervention strategies addressing the ways in which providers’ conscious and unconscious beliefs about patients mediate racial/ethnic disparities in treatment. It will be difficult to develop effective intervention strategies without a deeper understanding of how the context in which providers train and practice influences these processes. There is a great need for innovative studies examining the degree to which changes in reimbursement methodologies, organizational factors, provider education, and professional norms—including adherence to clinical practice guidelines—influence disparities in care.
Our findings also highlight the urgent need for discourse and consensus development on the role of social factors in clinical decisionmaking. What factors should matter? When should they matter? What valid and reliable methods can clinicians use to assess patients’ status on these factors and thus avoid reliance on "base rates"60,61 or stereotypes? What changes in organization, delivery, and reimbursement methodologies are needed to support such strategies? Failure to attend to these issues will in all likelihood condemn us to continuing inequities in—and thus, variable quality of—health care and health outcomes.
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Acknowledgments |
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We wish to acknowledge Edward D. Hannan for his efforts in conceptualizing and directing the medical record abstraction portions of the original study; Jane Burke for her excellent project management of the original study; Hanna Bloomfield, director of the Center for Chronic Disease Outcomes Research, for her leadership in finding protected time for writing; and H. Jack Geiger for his helpful comments on earlier presentations of these results.
Human Participant Protection
This study was approved by the University of Albany’s institutional review board. Participants provided informed consent to take part in the study.
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Footnotes |
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Contributors
M. van Ryn originated the study, supervised all aspects of its implementation and conceptualization, and led the writing. D. Burgess, J. Malat, and J. Griffin helped to conceptualize ideas, interpret findings, and review and revise drafts of the article.
Accepted for publication January 29, 2005.
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References |
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