Does Patient-Provider Racial, Ethnic, and Language Concordance Matter? Nelly Song

Does Patient-Provider Racial, Ethnic, and Language Concordance Matter? Nelly Song

Thesis Statement Historical and current studies have shown that patients receive better care when concordant with their doctors in various aspects of their lives, including their race, ethnicity, and/or language. Unfortunately, there is a large gap in the concordance rate of physicians and patients. While Hispanics, African Americans, and Native Americans represent more than 25 percent of the U.S. population, they comprise fewer than 6 percent of doctors [Cooper]. Moreover, there is a growing Hispanic patient population that is widening this gap. As a result, recruitment of physicians of particular race, ethnicity, and/or language that will tailor to the medical needs of the growing diverse patient population in the health profession is needed.

Introduction Cooper et al. and many other groups recommend that health policy be revised to encourage workforce diversity by funding programs that support the recruitment of minority students and medical faculty [Cooper]. To improve clinical practice and health care delivery, health systems should optimize their providers ability to establish rapport with minority patients [Cooper]. Cultural competency training should be incorporated into the education of health professionals [Cooper]. Finally, future research should provide additional insight into the mechanisms by which concordance of patient and physician race, ethnicity, and language affects processes and outcomes of care [Cooper]. Patients in raceconcordant relationships with their physicians rated their physicians decision-making styles as significantly more participatory and their care more satisfactory overall than patients in race-discordant relationships [Cooper].

Discussion The most compelling argument for a more diverse health professions workforce is that it will lead to improvements in public health [HRSA]. The U.S. Department of Health and Human Services Health Resources and Services Administration [HRSA] reviewed a total of 55 studies addressing four separate hypotheses: The service patterns hypothesis: that health professionals from racial and ethnic minority and socioeconomically disadvantaged backgrounds are more likely than others to serve racial and ethnic minority and socioeconomically disadvantaged populations, thereby improving access to care for vulnerable populations and in turn, improving health outcomes [HRSA]. The concordance hypothesis: that increasing the number of racial and ethnic minority health professionals by providing greater opportunity for minority patients to see a practitioner from their own racial or ethnic group or, for patients with limited English proficiency, to see a practitioner who speaks their primary language will improve the quality of communication, comfort level, trust, partnership, and decision making in patient-practitioner relationships, thereby increasing use of appropriate health care and adherence to effective programs, ultimately resulting in improved health outcomes [HRSA]; The trust in health care hypothesis: that greater diversity in the health care workforce will increase trust in the health care delivery system among minority and socioeconomically disadvantaged populations, and will thereby increase their propensity to use health services that lead to improved health outcomes [HRSA]; and The professional advocacy hypothesis: that health professionals from racial and ethnic minority and socioeconomically disadvantaged backgrounds will be more likely than others to provide leadership and advocacy for policies and programs aimed at improving health care for vulnerable populations, thereby increasing health care access and quality, and ultimately health outcome for those populations [HRSA]. However, insufficient evidence exists as to whether greater health professions diversity leads to greater trust in health care or greater advocacy for disadvantaged populations [HRSA]. All in all, these findings indicate that greater health professions diversity will likely lead to improved public health by increasing access to care for underserved populations, and by increasing opportunities for minority patients to see practitioners with whom they share a common race, ethnicity or language [HRSA]. Race, ethnicity, and language concordance, which are associated with better patient-practitioner relationships and communication, may increase patients likelihood of receiving and accepting appropriate medical care [HRSA].

Evidence in Lung Cancer Risk A controlled experiment assessed whether perceived physician race influenced African-American patients (n=127) risk perception accuracy following the provision of objective lung cancer risk information [Persky]. Participants interacted with a virtual reality-based, simulated physician who provided personalized cancer risk information (Figure 1) [Persky]. Participants who interacted with a racially discordant virtual physician were less accurate in their risk perceptions at post-test than those who interacted with a concordant virtual physician, F(1,94)=4.02, p=.048 (Figure 2)[Persky]. This effect was amplified among current smokers [Persky]. Effects were not mediated by trust in the provider, engagement with the health care system, or attention during the encounter [Persky]. The current study demonstrates that African-American patients perceptions of a physician s race are sufficient to independently impact their processing of lung cancer risk information [Persky].

Figure 1. Racially Concordant and Racially Discorcodant Versions of the Reality Physician [Persky]

Figure 2. Risk Perception Inaccuracy by Condition and Smoking Status, Raw Means [Persky].

Evidence in Starting HIV Medication King et al. examined patients with HIV, and found that compared to whites, African Americans have been found to have greater morbidity and mortality from HIV, partly due to their lower use of effective antiretroviral therapy. King et al. examined whether racial concordance affects the time of receipt of protease inhibitors [King]. They analyzed data from a prospective, cohort study of a national probability sample of 1,241 adults receiving HIV care with linked data from 287 providers [King]. Of the 1,241 patients, 61% (803) were white with white providers, 32% (341) were African-American with white providers, 6% (86) were African-American with African-American providers, and less than 1% (11) were white with African-American providers (Table 1). They also compared the provider characteristics of those caring for the different patient-provider racial groups (Table 2). Overall, they examined the association between patient-provider racial concordance and time from when the FDA approved the first protease inhibitor to the time when patients first received a protease inhibitor [King]. In their unadjusted model, white patients received protease inhibitors much earlier than African-American patients (median 277 days compared to 439 days; P <.0001) [King]. Adjusting for patient characteristics only, African-American patients with white providers received protease inhibitors significantly later than African-American patients with African-American providers (median 461 days vs. 342 days respectively; P <.001) and white patients with white providers (median 461 vs. 353 days respectively; P =.002) [King]. In this model, no difference was found between African-American patients with African-American providers and white patients with white providers (342 vs.353 days respectively; P > 0.20) [King]. Adjusting for patients trust in providers, as well as other patient and provider characteristics in subsequent models, did not account for these differences [King]. African-American patients with white providers still had significantly later use of protease inhibitors compared to other patients after additionally adjusting for provider characteristics, which were specialty training, HIV expertise, HIV knowledge, years in practice, gender, sexual preference, patient care mix, type of practice, preference not to treat injection drug users, and the belief that most of their patients can adequately adhere to their medication regimen (Table 3, Stage 3 model), as well as after adjusting for patient s ratings of their medical care, trust in their provider, and belief that antiretrovirals are worth taking (Table 3, Stage 4 model). These results were similar in a sensitivity analysis excluding nurse practitioners/physician assistants and their patients.

Table 1. Weighted Comparison of Patient characteristics Stratified According to Patient-Provider Race Groups [King].

Table 2. Weighted Comparison of provider Characteristics Stratified According to Patient-Provider Race Groups [King].

Table. Unadjusted and Adjusted Days Until First Protease Inhibitor Use by Patient-Provider Race Groups (95% Confidence Interval) [King]

Conclusion Current evidence supports the notion that there are racial, ethnic, and language health disparities and that patient-physician racial, ethnic, and language concordance does matter and does lead to better public health outcomes in many situations. Moreover, greater workforce diversity may lead to improved public health, primarily through greater access to care for underserved populations and better interpersonal interactions between patients and health professionals [HRSA]. Hence, programs and policies that promote racial, ethnic, and socioeconomic diversity in the health professions are based on the principle that a more diverse health care workforce will improve public health. Numerous public and private programs have aimed to remedy this underrepresentation by promoting the preparedness and resources available to minority and socioeconomically disadvantaged health professions candidates, and the admissions and retention of these candidates in the health professions pipeline and workforce [HRSA]. In recent years, however, competing demands for resources, along with shifting public opinion about policies aimed to assist members of specific racial and ethnic groups, have threatened the base of support for diversity programs [HRSA]. Continued support for these programs will increasingly rely on evidence that they provide a measurable public benefit [HRSA].

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