R-e-s-p-e-c-t: patient reports of disrespect in the health care setting and its impact on care

Journal of Family Practice, Sept, 2004 by Janice Blanchard, Nicole Lurie

Abstract

Objective The health care encounter is a setting in which racial/ethnic disparities can arise. Patients who experience disrespect in this encounter may be less likely to use health care services that improve outcomes. The objective of this study was to examine factors in the health care encounter and to model how negative perceptions of the encounter influence health care utilization.

Design, subjects, and setting Data were derived from the Commonwealth Fund 2001 Health Care Quality Survey, a nationwide random-digit-dial survey of 6722 adults, conducted between April 30 and November 5, 2001. Bivariate and multivariate analyses were performed on weighted data.

Main outcome measures Measures of negative perceptions of the patient-provider relationship included feelings of being treated with disrespect or being looked down upon, a belief that unfair treatment was received due to race or language spoken, and a belief that better treatment would have been received had the respondent had been of a different race. Measures of utilization included receipt of a physical exam within the prior year, receipt of optimal cancer screening and recommended elements of chronic disease care, delay of needed care, and not following the doctor's advice.

Main results Minorities were significantly more likely to report being treated with disrespect or being looked down upon in the patient-provider relationship. Specifically, 14.1% of blacks (P=.06), 19.4% of Hispanics (P<.001), and 20.2% if Asians (P<.001) perceived being treated with disrespect or being looked down upon, compared with only 9.4% of whites. Persons who thought that they would have received better treatment if they were of a different race were significantly less likely to receive optimal chronic disease screening and more likely to not follow the doctor's advice or put off care (P<.01.)

Conclusions Perceptions of disrespect or of receiving unfair treatment within the patient-provider relationship are prevalent, particularly among racial/ethnic minorities. Such negative perceptions influence health care utilization and may contribute to existing health disparities.

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Racial and ethnic disparities in health care have been catalogued across numerous diseases and care settings. (1) By clarifying the causes of these disparities, we can develop solutions. In a seminal study, Shulmano found in patient simulations that identical presentations for heart disease received different recommendations for care based on the patient's race and gender, thus pinpointing the patient-provider relationship as a potential source of disparities. (2) Other research suggests interactions with non-physician health care personnel might also be a source of negative experiences with care. (3)

Research is beginning to identify how the health care encounter might relate to disparities in use of services and quality of care. For example, race concordance between the physician and patient, at least for blacks, is associated with higher patient satisfaction and greater participatory decision-making. This in turn can impact compliance and possibly outcomes. (4-6) While black patients who have black physicians are more likely to report receipt of counseling about preventive care and cancer screening, (7) race concordance does not appear to be independently associated with different patterns of utilization. (8)

Perceived discrimination has also been associated with lower levels of satisfaction with the health care system. (9) In one survey, two thirds of respondents reported feeling discriminated against in their interactions with health care providers due to their race or socioeconomic status. (10) How perceived discrimination influences quality and outcomes of care has not been fully explored.

We hypothesized that minority patients and those who do not speak English perceive negative experiences with the health care encounter more often than whites or English-speakers. We further hypothesized that patients who report such negative experiences are less likely to seek care initially or return for follow-up care. We tested these hypotheses using data from the Commonwealth Fund 2001 Health Care Quality Survey.

* METHODS

Sample

Respondents were from a nationally representative sample of 6722 adults, aged 18 years and older, living in the continental United States, and who speak English, Spanish, Mandarin, Cantonese, Vietnamese, or Korean.

The sampling frame was based on random-digit dialing; telephone exchanges with higher-than-average numbers of minority households were oversampled. In addition to the oversampling based on telephone exchanges, we interviewed members of 394 households identified from a nationwide demographic tracking survey as having an Asian/Asian American or African American family member. Interviews were conducted in English, Spanish, Mandarin, Cantonese, Vietnamese, or Korean, depending on the respondent preference. The response rate for the entire sample was 53.1%.

The final sample was weighted to correct for the disproportionate sample design and to ensure the sample was representative of all adults aged 18 years and older based on the March 2001 Current Population Survey (CPS). The final weighted sample is therefore reflective of the 193 million adults in the United States who have telephones. A more detailed description of the sampling and weighting methods can be found elsewhere. (11) Data were collected between April 30 and November 5, 2001.