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Factors that impede access to care and patient satisfaction are explored in three recent studies

Several new studies supported by the Agency for Healthcare Research and Quality examine issues that impede access to care or affect care satisfaction. The first AHRQ-supported study (HS11386) suggests that racial/ethnic minorities and people who have limited English proficiency face barriers to care other than financial barriers. The second AHRQ-supported study (HS10771 and HS10856) reveals that individuals who live in a community with a higher prevalence of gatekeeping—when a person must be referred to a specialist by their primary care provider—report less trust in their physicians, a factor essential to high quality health care, than individuals who live in communities with less gatekeeping activity independent of the individual's personal gatekeeping requirements. The third AHRQ-supported study (HS06167) suggests that patient satisfaction with primary care doctors is influenced by the sex of the doctor. The articles are summarized here.

Weech-Maldonado, R., Morales, L.S., Elliott, M., and others (2003, June). "Race/ethnicity, language, and patients' assessments of care in Medicaid managed care." Health Services Research 38(3), pp. 789-808.

These investigators examined the care assessments of 49,327 adults enrolled in Medicaid managed care plans in 14 States in 2000 using data derived from the national Consumer Assessment of Health Plans Study (CAHPS®) Benchmarking Database. Racial/ethnic minorities had lower reports of care than white English speakers, especially for timeliness of care (prompt receipt of urgent and routine care) and staff helpfulness (courtesy and respect). On the other hand, racial/ethnic minorities and those with limited English were similar to white English speakers in their ratings of health plan customer service. This pattern may have resulted from State Medicaid agency requirements that organizations address the service needs of these minority groups.

Language proficiency independently affected care experience. Among Asians, English speakers had care experiences similar to those of whites. Non-English speaking Asians had the lowest reports and ratings of care of all racial/ethnic groups studied. Similarly, among whites and Hispanics, non-English speakers had worse reports and ratings of care than either English or bilingual speakers.

These findings suggest the need to go beyond financial access to address nonfinancial barriers to care. Potential remedies include establishing interpreter services, providing staff training in cultural competency, using community health workers, and promoting culturally appropriate health care services.

Haas, J., Phillips, K.A., Baker, L.C., and others (2003). "Is the prevalence of gatekeeping in a community associated with individual trust in medical care?" Medical Care 41, pp. 660-668.

Many managed care plans require that the primary care doctor serve as a gatekeeper for referrals to specialists. Living in a community where there is a higher prevalence of this gatekeeping arrangement diminishes patients' trust in their primary care doctor independent of an individual's personal insurance coverage, according to this study. The researchers analyzed responses from two surveys: the Community Tracking Survey (CTS), a nationally representative survey of households in 60 communities; and the CTS Physician Survey of 10,881 direct patient care physicians in the same 60 communities. Physicians were asked about their gatekeeping role, if any. Individuals were asked about their experience with the health care system, insurance and health status, and sociodemographic characteristics.

Analysis of findings was confined to respondents with health insurance, a usual source of care, and at least one physician visit. Compared with individuals living in communities with the lowest prevalence of gatekeeping activity, those living in communities with the highest prevalence were 23 percent less likely to agree strongly that they trusted their doctor to put their medical needs above all other considerations.

A higher prevalence of gatekeeping in the community was also positively associated with the perception that a doctor was strongly influenced by insurance company rules when making decisions about medical care. Conversely, a higher prevalence of gatekeeping in the community was negatively associated with the perception that a doctor might perform an unnecessary test or procedure.

Bertakis, K.D., Franks, P., and Azari, R. (2003). "Effects of physician gender on patient satisfaction." Journal of the American Medical Women's Association 58(2), pp. 69-75.

Women now constitute nearly half of all first-year students entering medical school. In this study, patients of female physicians were more satisfied with their physician than patients of male physicians. This held true, even after adjusting for patient characteristics, visit length, and physician practice style behaviors. The psychosocial aspect of the physician-patient interaction may be different for male physicians. Women physicians tend to engage in more positive talk and more partnership building, provide more information, and are more psychosocially oriented. On the other hand, patients may presume female physicians are more gentle, empathetic, and nurturing and, consequently, respond with more self-disclosure and information, suggest the researchers.

They randomized 509 new adult patients to see either a male or female primary care physician at a university medical center outpatient facility. They measured the patients' health status and sociodemographic characteristics before the initial visit, and they measured satisfaction with the physician immediately following the videotaped visit. Overall, the sex of the physician was associated with a 27 percent change in satisfaction.

Female physicians spent substantially more time than male physicians on preventive services and counseling, while male physicians devoted more time to technical practice behaviors and discussions of substance abuse. The length of these initial visits did not differ significantly between male and female physicians.

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