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Physician Effects on Racial and Ethnic Disparities in Patients’ Experiences of Primary Care

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Abstract

Background

Few studies have clarified the mechanisms that contribute to racial and ethnic disparities in primary care quality among comparably-insured patients.

Objective

To examine relative contribution of “between-” and “within-” physician effects on disparities in patients’ experiences of primary care.

Design

Regression models using physician fixed effects to account for patient clustering were specified to assess “between-” and “within-”physician effects on observed racial and ethnic disparities in patients’ experiences of primary care.

Participants

The Ambulatory Care Experiences Survey (ACES) was administered to patients visiting 1,588 primary care physicians (PCPs) from 27 California medical groups. The analytic sample included 49,861 patients (31.4 per PCP) who confirmed a PCP visit during the preceding 12 months.

Main Results

Most racial and ethnic minority groups were significantly clustered within physician practices (p < 0.001). “Between-physician” effects were mostly negative and larger than “within-physician” effects for Latinos, Blacks, and American Indian/Alaskan Natives, indicating that disparities are mainly attributable to patient clustering within physician practices with lower performance on patient experience measures. By contrast, “within-physician” effects accounted for most disparities for Asians and Pacific Islanders, indicating these groups report worse experiences relative to Whites in the same practices. Practices with greater concentration of Blacks, Latinos and Asians had lower performance on patient experience measures (p < 0.05).

Conclusions

Targeting patient experience improvement efforts at low performing practices with high concentrations of racial and ethnic minorities might efficiently reduce disparities. Urgent study is needed to assess the contribution of “within-” and “between-” physician effects to racial and ethnic disparities in the technical quality of primary care.

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Acknowledgements

This project was supported by research grants from the Commonwealth Fund (#20070067) and the Center for Statistics and the Social Sciences with funds from the University Initiatives at the University of Washington. We would like to thank Justin Reedy, Gary Segura and the anonymous reviewers for suggestions that significantly strengthened the analysis.

Conflict of Interest

None disclosed.

Author information

Authors and Affiliations

  1. Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle, WA, USA

    Hector P. Rodriguez Ph.D., MPH & David E. Grembowski Ph.D.

  2. Pacific Business Group on Health, San Francisco, CA, USA

    Ted von Glahn MS

  3. Tufts Medical Center, Boston, MA, USA

    William H. Rogers Ph.D. & Dana Gelb Safran Sc.D.

Authors
  1. Hector P. Rodriguez Ph.D., MPH
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  2. Ted von Glahn MS
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  3. David E. Grembowski Ph.D.
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  4. William H. Rogers Ph.D.
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  5. Dana Gelb Safran Sc.D.
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Corresponding author

Correspondence to Hector P. Rodriguez Ph.D., MPH.

Appendix

Appendix

Ambulatory Care Experience Survey (ACES) Composite and Item Content

ACES Measure

Item Content

Quality of physician–patient interaction

In the last 12 months…

…how often did this doctor explain things in a way that was easy to understand?1

…how often did this doctor listen carefully to you?1

…how often did this doctor give you easy-to-understand instructions about what to do to take care of the heath problems or concerns that were bothering you?1

…how often did this doctor seem to know the important information about your medical history?1

…how often did this doctor spend enough time with you?1

…how often did this doctor show respect for what you had to say?1

Health promotion support

In the last 12 months…

…did you and this doctor talk about a healthy diet and healthy eating habits?2

…did you and this doctor talk about the exercise or physical activity you get?2

Care coordination

In the last 12 months…

…how often did this doctor seem informed and up-to-date about the care you got from specialist doctors?1

…when this doctor sent you for a blood test, x-ray or other test, how often did someone from the doctor’s office follow-up to give you the test results?1

Organizational access

In the last 12 months…

…when you called this doctor’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you thought you needed it?1

…when you made an appointment for a check-up or routine care with this doctor, how often did you get an appointment as soon as you thought you needed it?1

…when you called this doctor’s office with a medical question during regular office hours, how often did you get an answer to your question that same day?1

…when you called this doctor’s office after regular office hours, how often did you get the medical help or advice you needed?1

Wait time includes times spent in the waiting room and exam room. In the last 12 months, how often did your visits at this doctor’s office start within 15 minutes of your appointment? 1

Office staff interactions

In the last 12 months…

…how often were clerks and receptionists at this doctor’s office as helpful as you thought they should be?1

…how often did clerks and receptionists at this doctor’s office treat you with courtesy and respect?1

Willingness to recommend physician

Would you recommend this doctor to your family and friends?3

  1. Notes: Response Continuums: 1 = Never, Almost never, Sometimes, Usually, Almost always, Always; 2 = Yes, definitely, Yes, somewhat, No, definitely not; 3 = Definitely yes, Probably yes, Not sure, Probably not, Definitely not

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Rodriguez, H.P., von Glahn, T., Grembowski, D.E. et al. Physician Effects on Racial and Ethnic Disparities in Patients’ Experiences of Primary Care. J GEN INTERN MED 23, 1666–1672 (2008). https://doi.org/10.1007/s11606-008-0732-8

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