Health care discrimination, processes of care, and diabetes patients’ health status

https://doi.org/10.1016/j.pec.2004.12.001Get rights and content

Abstract

Objective

We examined whether diabetes patients report discrimination when seeking health care, whether problems with interpersonal processes of care (IPC) were associated with discrimination reports, and the linkage between discrimination and patients’ health.

Methods

810 diabetes patients were surveyed. Surveys were linked to hemoglobin A1c (A1C) and total cholesterol test results.

Results

14% of participants reported experiencing discrimination in health care during the prior year, including discrimination due to their race (8%), education or income (9%), age (7%), and gender (10% of women). Patients with poorer than average ratings of their IPC had 2–8 times greater risk of reporting health care discrimination. Patients reporting health care discrimination had A1C levels that were higher than other patients (P = 0.002), more symptoms (P < 0.01), and poorer physical functioning (P = 0.007).

Conclusions

Diabetes patients’ reports of health care discrimination are strongly linked to the quality of their interactions with providers as well as multiple health outcomes.

Practice implications

Physicians exert control over the clinical encounter and should endeavor to reduce patients’ perceptions of discrimination during outpatient visits. Such efforts may result in more satisfied patients as well as improved health outcomes.

Introduction

Sociodemographic disparities in health care utilization and outcomes have been well-documented [1], [2], [3], [4], and these disparities raise concerns as to whether clinicians, administrative staff, or health care institutional policies are discriminatory. Outside of the health care context, as many as one third of adults in the US report experiencing “major” discrimination during their lifetime, and 7% report experiencing discrimination frequently in their daily lives [5], [6]. The health consequences of perceived discrimination are serious, and include worse self-rated health, mental health [7], [8], [9], [10], cardiovascular reactivity and high blood pressure [11], [12], as well as the presence of cardiovascular risk factors such as greater waist circumference and abdominal obesity [13].

Relatively few studies have focused on the extent to which patients experience discrimination in health care settings or whether such experiences are associated with the process and outcomes of their care [14], [15], [16]. In a study of African American adults [17], more than half reported experiencing racial discrimination by health care providers during their lifetime, and 59% reported discrimination by clinicians based on their socioeconomic status. The Commonwealth Fund Minority Health Study [18] found that 4% of African Americans reported being “treated badly” within health care settings during the prior year because of their race, and 5% reported being treated badly due to their income level. In another study, African American cardiac patients were four times more likely than whites to report that “racial discrimination in a doctor's office is common [19].” Perhaps not surprisingly, patients reporting health care discrimination are less satisfied with their care and more likely to report a delay in seeking needed services [15], [19], [20]. Although perceived health care discrimination may contribute to the relatively poor health of many ethnic and racial minorities, to our knowledge there have been no prior studies examining this relationship.

We examined the prevalence of self-reported health care discrimination within a sociodemographically diverse sample of patients with diabetes. Because the interpersonal dynamic between health care providers and patients may influence patients’ perceptions of discrimination, we explored the association between self-reported discrimination and patients’ reports of the interpersonal processes of their care. We also examined the association between self-reported discrimination and patients’ health. Because diabetes disproportionately affects ethnic minorities and those of lower socioeconomic status [21], this research may have strategic implications for the reduction of racial, ethnic, and socioeconomic disparities in diabetes care called for in Healthy People 2010 [22].

Section snippets

Participants

Adults with diabetes treated in the United States in a county health care system (located in San Francisco, CA), a university-based health care system (San Francisco, CA), and three Department of Veterans Affairs (VA) health care systems (San Francisco, CA; Palo Alto, CA; Madison, WI) were identified as part of a larger study [23], [24]. Participating health systems were a convenience sample of facilities with which the study investigators were affiliated. In each system of care, we identified

Respondent characteristics

The sample of 810 survey respondents included 397 white patients (49%), 152 African Americans (19%), 114 Hispanics (14%), and 147 patients who were Asian, Pacific Islander, or of other race/ethnicities (18%). One third of the sample (259 patients) was female, and a range of age, education, and income levels was represented (Table 1). The average patient had moderately good glycemic control and cholesterol control; however patients reported more than five symptoms on average and reported poor

Discussion

To our knowledge, this is the first study to quantify the prevalence of self-reported health care discrimination among patients with diabetes and to demonstrate that self-reported discrimination is independently associated with worse glycemic control, greater symptom burden, and worse physical functioning. We further demonstrated that patients with worse ratings of the interpersonal processes of their care were substantially more likely to report various forms of health care discrimination. We

Practice implications

This study suggests that physicians should be aware of perceptions of discrimination on the part of patients and the strong association between patients’ discrimination reports and health outcomes. Physicians should examine their own potential biases and consider the possibility that conscious or unconscious stereotyping may influence their behaviors, including their interpersonal style. Physicians must also be aware that their practice style is interpreted by patients within the context of

Acknowledgements

Dr. Piette is a Department of Veterans Affairs (VA) Career Scientist. The views expressed in this report do not necessarily reflect the positions of the VA.

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