Presentation on theme: "Assessing the Role of the Physician and Practice Setting in Child Health Disparities Lauren A. Smith 1, Andrew Johnson 2, Carol J. Simon 2 1 Boston University."— Presentation transcript:
Assessing the Role of the Physician and Practice Setting in Child Health Disparities Lauren A. Smith 1, Andrew Johnson 2, Carol J. Simon 2 1 Boston University School of Medicine 2 Abt Associates and Boston University School of Public Health Supported by grants from Agency for Healthcare Research and Quality, The California Endowment & The Commonwealth Fund
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
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
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
Race/Ethnicity Variation in Vignettes VignetteNameRace/ethnicity 1aElenaLatina 1bAishaAfrican American 1cKristenWhite 2aJoséLatino 2bDarnellAfrican American 2cToddWhite
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.
Vignette 1 Results by Race Clinical management Total N=771 % White N=260 % Black N=251 % Latino N=260 % Dx=adolescent response very likely 232522 Dx=depression very likely 39423639 Observe17141619 Refer to mental health provider 70716870 No medical therapy81 8280 Start anti-depressant18 1619
Vignette 1 Results by Practice/Patient Characteristics Clinical managementLatino PatientsBlack patients <20% N=296 % 40% N=211 % <20% N=466 % 40% N=73 % Dx=adolescent response very likely 232723 Dx=depression very likely37404232* Observe, reassess16181619 Refer to mental health provider 73677260* No medical therapy8182 85 Start anti-depressant18151815
Vignette 1 Results by Practice/Patient Characteristics Clinical managementLEP PatientsMedicaid patients <20% N=463 % 40% N=121 % <20% N=355 % 40% N=225 % Dx=adolescent response very likely 2128*2129* Dx=depression very likely40434036 Observe, reassess1424*1418 Refer to mental health provider 7366*7464* No medical therapy8188**8481 Start anti-depressant18131519
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.
Vignette 2 Results by Race Clinical managementTotal N=771 % White N=260 % Black N=251 % Latino N=260 % Dx=mild persistent33353032 Dx=mod persistent59566159 Check peak flow69716769 Asthma action plan88898788 Refer to asthma specialist21202221 Inhaled corticosteroids seasonally/short period 23262321 Inhaled corticosteroids year round 71726973
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
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