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Studies examine influence of patient race on primary care quality and hospital discharge against medical advice

Numerous studies document disparities in care among racial/ethnic minorities compared with whites. However, a new study found that the content of primary care visits did not differ based on the racial composition of physicians' practices. A second study found that racial differences in being discharged from the hospital against medical advice largely disappeared after accounting for individual and hospital socioeconomic factors. Both studies were supported by the Agency for Healthcare Research and Quality (HS10910) and led by Kevin Fiscella, M.D., M.P.H., of the University of Rochester School of Medicine, and Peter Franks, M.D., of the University of California, Davis. They are summarized here.

Fiscella, K., and Franks, P. (2006, April). "Does the content of primary care visits differ by the racial composition of physicians' practices?" American Journal of Medicine 119, pp. 348-353.

Based on commonly performed procedures during medical visits, the researchers found that primary care physicians with a large proportion of black patients do not provide inferior care compared with their colleagues with a small proportion of black patients. Procedures ranged from Pap smears and vision screening to cholesterol and blood pressure checks, diet and exercise counseling, and mammography screening. In the study, a relatively small proportion of providers (24 percent of physician practices) provided 80 percent of all primary care visits by black patients. This may have been due to a combination of continuing residential racial segregation, as well as racial differences in presence and type of insurance, explain the researchers.

They analyzed the content of office visits using 1997 to 2002 data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. The data revealed few differences in the overall content of visits based on the proportion of black patients in the physician's practice. Only 1 of 16 office procedures (rectal exams) had a difference that approached significance. Physicians whose practice had a larger proportion of black patients were slightly less likely to perform rectal exams or provide mental health counseling than those with a smaller proportion of black patients. They were significantly less likely to refer patients to specialists, but were more likely to schedule a return appointment.

Previous studies have shown that physician practices with a large black population report more difficulty accessing specialty care. More return appointments may reflect the need of these physicians to follow up on problems that otherwise would have been managed by a specialist. More return appointments also may reflect incomplete adjustment for greater severity of illness among black patients, suggest the researchers.

Franks, P., Meldrum, S., and Fiscella, K. (2006, August). "Discharges against medical advice: Are race/ethnicity predictors?" Journal of General Internal Medicine 21, pp. 955-960.

This study found that blacks were twice as likely as whites to be discharged against medical advice (DAMA) at hospitals in three States. Hispanics also had a higher rate of DAMA, while Asian and "other" ethnic groups were less likely than whites to be DAMA. However, racial/ethnic disparities in DAMA largely disappeared once individual and hospital socioeconomic factors were considered. Patient risk factors for DAMA included younger age, male gender, nonelective admission, Medicaid insurance, no insurance, and fewer coexisting medical conditions. Specific coexisting conditions were also associated with greater DAMA risk: HIV/AIDS, liver disease, alcohol or drug abuse, and psychiatric diagnoses other than depression.

Hospital risk factors for DAMA included location in large urban areas, hospitals with a greater proportion of minorities and patients with Medicaid, and the least and most specialized hospitals. Also, patients admitted to non-profit hospitals had lower risk of DAMA. After full adjustment for biomedical and other factors, as well as patient socioeconomic factors and hospital characteristics, the increased risk for DAMA for blacks was eliminated, and Hispanics had lower risk for DAMA.

Neither minority race nor ethnicity status was independently associated with increased risk for DAMA at the individual level. This finding suggests that racial discrimination and poor communication at the individual level are not primary factors in DAMA. Rather, place of hospitalization, income, and insurance contribute to DAMA. The findings were based on analysis of hospital discharge data on adults admitted to hospitals in California, Florida, and New York from 1998 to 2000, which was linked to American Hospital Association data on hospital characteristics.

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