Elsevier

Social Science & Medicine

Volume 62, Issue 1, January 2006, Pages 103-115
Social Science & Medicine

Patient characteristics and inequalities in doctors’ diagnostic and management strategies relating to CHD: A video-simulation experiment

https://doi.org/10.1016/j.socscimed.2005.05.028Get rights and content

Abstract

Numerous studies examine inequalities in health by gender, age, class and race, but few address the actions of primary care doctors. This factorial experiment examined how four patient characteristics impact on primary care doctors’ decisions regarding coronary heart disease (CHD).

Primary care doctors viewed a video-vignette of a scripted consultation where the patient presented with standardised symptoms of CHD. Videotapes were identical apart from varying patients’ gender, age (55 versus 75), class and race, thereby removing any confounding factors from the social context of the consultation or other aspects of patients’ symptomatology or behaviour. A probability sample of 256 primary care doctors in the UK and US viewed these video-vignettes in a randomised experimental design.

Gender of patient significantly influenced doctors’ diagnostic and management activities. However, there was no influence of social class or race, and no evidence of ageism in doctors’ behaviour. Women were asked fewer questions, received fewer examinations and had fewer diagnostic tests ordered for CHD. ‘Gendered ageism’ was suggested, since midlife women were asked fewest questions and prescribed least medication appropriate for CHD. Primary care doctors’ behaviour differed significantly by patients’ gender, suggesting doctors’ actions may contribute to gender inequalities in health.

Introduction

Sociological and epidemiological research on inequalities in health by gender, age, social class and race has largely neglected the actions of health care providers. The dominant paradigm emphasises patient characteristics, including socio-economic status, family background, level of deprivation, working conditions, social support, psycho-social characteristics, lifestyle risk factors and social capital (Bartley, Sacker, Firth, & Fitzpatrick, 1999; Macintyre, 1997). Researchers less often consider supply side factors associated with doctors’ actions as potential sources of health inequalities, e.g. recent books on health inequalities pay scant attention to supply side factors (cf. Bartley, Blane, & Davey-Smith, 1998; Graham, 2000; Mackenbach & Bakker, 2002).

The supply side factor addressed here is whether there is differential ‘processing of patients’ by primary care providers according to patients’ social characteristics. McKinlay (1975) examined how different types of organisations process people. There has been more research on processing patients within hospital than primary care. This paper employs a factorial experiment to examine whether four patient characteristics—gender, age, social class and race—influence diagnostic and management decisions of primary care doctors in the UK and US when standardised symptoms of coronary heart disease (CHD) are presented.

Primary care doctors are ‘gatekeepers’ to secondary care (Forrest, 2003); their initial decisions determine how patients are subsequently processed through the healthcare system, including their investigations and treatment. If patients’ social characteristics influence how primary care doctors diagnose and manage patients, specific groups of patients may be disadvantaged in treatments received in primary care and/or less likely to be referred for secondary care. We support Paterson and Judge's statement that ‘inequalities in access to secondary care may originate in, and therefore need to be addressed in, the primary care sector’ (2002, p. 170).

Primary care physicians are increasingly acting as gatekeepers to specialists and other medical resources in the US (Forrest, 2003), while UK general practitioners have traditionally performed this role. The UK and US represent contrasting healthcare systems with different payment and funding mechanisms, organisational structures and systems of medical education. The paper uses pooled data from primary care practitioners in the US and UK, examining whether patients’ social characteristics have comparable effects on doctors’ behaviour in these two countries.

CHD provides an exemplar condition for this study of how primary care doctors process patients. It is the main cause of death for both women and men (Lawlor, Ebrahim, & Davey Smith, 2002a; Wenger, 1997), and commonly presented by midlife and older patients to primary care doctors in the US and UK. The varying rates of CHD by age, gender, social class and race might suggest that primary care doctors’ decisions would be influenced by knowledge of these risk profiles (base rates) according to patient characteristics.

Rates of CHD increase with advancing age, with age-specific CHD mortality higher among men than women (Lawlor, Ebrahim, & Davey Smith, 2002b). However, twice as many women as men aged 45–64 have undetected or ‘silent’ myocardial infarctions, suggesting later CHD diagnosis among women (McKinlay, 1996). Women with CHD delay longer before reaching hospital and present with more severe infarcts (Jackson, 1994), possibly reflecting lay beliefs about CHD as a primarily male disease (Emslie, Hunt, & Watt, 2001). CHD mortality has declined in most developed countries over recent years, with greater declines for men than women (Peltonen, Lundberg, Huhtasaari, & Asplund, 2000). Women have poorer prognosis than men following acute myocardial infarction, after adjusting for clinical covariates (Marrugat, Gil & Sala, 1999). These studies suggest a need for research on health care received by women first presenting with CHD symptoms.

Lower socio-economic groups experience higher rates of CHD, with greater falls in rates among higher than lower social classes (Barnett, Armstong, & Cooper, 1999; Davey-Smith, Hart, Watt, Hole, & Hawthorne, 1998; Kaplan & Keil, 1993; Lawlor et al., 2002a). Blacks experience higher rates of CHD than whites, resulting in a growing racial divide in CHD mortality (Barnett et al., 1999). Higher levels of cardio-vascular disease indicators among older US blacks are not explained by their poorer socio-economic status (Rooks et al., 2002).

Extensive research has shown differential CHD treatment of women and men within secondary care. Raine's (2000) systematic review of CHD found women are less likely than men to undergo non-invasive diagnostic investigations and receive less surgical treatment. In the US and UK, significantly fewer women than men undergo coronary angiography or bypass surgery (Ayanian & Epstein, 1991; Dudley et al., 2002; McKinlay, 1996; Sharp (1994), Sharp (1998); Shaw et al., 2004). Beery's (1995) theoretical discussion of gender bias in CHD-related referrals for diagnostic and therapeutic procedures suggests that gender stereotypes, such as men viewed as more stoical and only likely to complain when really sick, influence doctors’ management decisions. The American Medical Association's Council on Ethical and Judicial Affairs (CEJA, 1991) state that physicians need to look for hidden cultural or social bias in their clinical decisions.

Research on gender differences in CHD treatment primarily uses an inequalities framework, whereas research on age differences in treatment is largely characterised as rationing—whether older patients receive lower quality or quantity of health care. The UK government has come out against ageism in the National Service Framework (NSF) for Older People, where Standard 1 is targeted at ‘rooting out age discrimination’ (DoH, 2001). Although, this rules out using age as an explicit rationing criterion, age may still implicitly influence doctors’ decisions about diagnostic testing and referral (Locock, 2000).

It is important to integrate studies of age-related rationing with research on gender differences in CHD diagnosis and treatment. Doctors may vary their diagnostic procedures or treatments in relation to the interaction of patients’ age and gender. Among patients admitted with acute myocardial infarction, Shaw et al. (2004) found lower levels of coronary artery bypass grafts among women, with the gender disadvantage in revascularisation rates greater above 75 than at ages 40–64. They note that ‘few studies have considered age and gender inequities in conjunction’.

Research has shown lower rates of surgical procedures for CHD among lower socio-economic groups and blacks compared with whites in the US (Kaplan & Keil, 1993). Similarly, Finnish blue collar workers have lower rates of coronary bypass operations than white collar, despite CHD mortality being twice as high amongst the former (Keskimaki, Koskinen, & Salinto, 1997). Hetemaa, Keskimaki, Manderbacka, Leyland, & Koskinen suggest that socioeconomic differences in coronary surgical rates could be caused “by physicians’ socially biased referral decisions” (2003, p. 184). Despite extensive research on bias in medical decision-making, scant attention has addressed patient characteristics (Bornstein & Emler, 2002).

The above studies have examined hospital treatment, Raine (2001, p. 400) states ‘Primary care physicians act as gatekeepers to specialist health services, yet this critical role in the healthcare system has been largely ignored by researchers in this field.’ The few available studies have used practice-based data or surveys. Ecological analyses of hospital procedures have shown lower rates of angiography and revascularisation in practices with high deprivation scores (Hippisley-Cox & Pringle, 2000). Practice-based data show that men with heart disease are more likely to receive lipid-lowering drugs than women, with a greater gender bias among the 45–54 than older age groups (Hippisley-Cox, Pringle, Crown, Meal, & Wynn, 2001), while DeWilde et al.(2003) found lower prescription of lipid lowering drugs with increased age, but no sex difference after adjustment for disease severity. A population-based survey in Boston of patients seeking care for heart symptoms found lower cardiologist referral rates among blacks, and white women received less CHD-related treatment than men (Crawford, McGraw, Smith, McKinlay & Pierson, 1994; McKinlay, 1996).

Analyses of practice databases and cross-sectional surveys primarily focus on prescribing or referrals, rather than the full range of actions of primary care doctors. While they indicate possible gender and age bias, they cannot assess whether patient characteristics per se influence doctors’ decisions, because it is impossible to control adequately for differences in symptomology or patients’ manner of presentation in the consultation (Raine, 2001). Patients from different social groups may express themselves in varying ways, be more or less assertive, or offer different types of information during the consultation. Thus, despite statistical controls for potentially confounding variables, the possibility remains that findings of these studies reflect other uncontrolled differences between patients. As Hippisley-Cox (2004, p. 412) observes these studies ‘do not tell us why inequalities arise or at what point in the total care pathway they are most likely to occur.’

Our research takes a different approach to these methodological difficulties. It addresses whether inequalities occur within the primary care pathway, by designing an experiment, which involved showing doctors videotapes of a scripted consultation in which patients presented with CHD symptoms in a standardised way. The videotapes were identical apart from varying patients’ gender, age (55 versus 75), class and race, and therefore removed any confounding from the social context of the consultation or other aspects of patients’ symptomatology or behaviour.

Section snippets

Aims

This paper aims to examine:

  • (1)

    To what extent four patient characteristics—gender, age, class and race (singly and in combination)—influence primary care doctors’ diagnostic and management decisions for patients presenting with identical symptoms of CHD?

  • (2)

    Whether there are significant differences between the UK and US in the influence of patient characteristics on primary care doctors’ diagnostic and management decisions?

  • (3)

    Given the risk profiles for CHD by gender, age, class and race, do doctors’

Methods

A 24 experimental design (Cochran & Cox, 1957) was conducted simultaneously in the UK and US to estimate the unconfounded effects of patient characteristics on doctors’ diagnostic and management decisions of patients presenting in a standardised way. ‘Patients’ in the video-vignette presented with seven signs and symptoms strongly suggestive of CHD including chest pressure; pressure worsened with exertion, stress and eating; relief after resting; discomfort for more than three months; pain

Results

Lower social classes and blacks are more likely to suffer from CHD than higher social classes and whites, therefore it was surprising that class was not significantly associated with any aspect of doctors’ information gathering or the four areas of patient management. There were no significant associations between race and doctors’ diagnostic actions, and only one with a management decision, namely higher referral of blacks to specialist cardiology facilities (27% of blacks and 15% of whites

Discussion

There are major methodological difficulties in researching whether primary care doctors’ diagnostic and management strategies are influenced by the socio-demographic characteristics of patients. The present study addressed these problems by developing video-vignettes of doctor–patient consultations in which ‘patients’ (played by professional actors) presented with standardised symptoms of CHD, but varying their gender, age (55 versus 75), class and race. A probability sample of 256 primary care

Acknowledgements

Research funded by National Institutes of Health, National Institute of Aging, Grant no. AG-16747. We are grateful to Alan Goroll, MD, Ted Stern, MD, John Stoeckle, MD (Massachusetts General Hospital), David Armstrong, PhD, FFPHM, FRCGP and Mark Ashworth, MRCP, MRCGP (United Medical Schools of Guys, Kings and St. Thomas's, London), Diane Ackerley, MBBS (Guildford and Waverley Primary Care Trust), Sue Venn (UK research administrator), Sam Colt and Cathie McColl (interviewers), and Nathan Hughes

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