标题：Physicians’ Perceptions of Patients’ Social and Behavioral Characteristics and Race Disparities in Treatment Recommendations for Men With Coronary Artery Disease
摘要：Objectives . A growing body of evidence suggests that provider decisionmaking contributes to racial/ethnic disparities in care. We examined the factors mediating the relationship between patient race/ethnicity and provider recommendations for coronary artery bypass graft surgery. Methods . Analyses were conducted with a data set that included medical record, angiogram, and provider survey data on postangiogram encounters with patients who were categorized as appropriate candidates for coronary artery bypass graft surgery. Results . Race significantly influenced physician recommendations among male, but not female, patients. Physicians’ perceptions of patients’ education and physical activity preferences were significant predictors of their recommendations, independent of clinical factors, appropriateness, payer, and physician characteristics. Furthermore, these variables mediated the effects of patient race on provider recommendations. Conclusions . Our findings point to the importance of research and intervention strategies addressing the ways in which providers’ beliefs about patients mediate disparities in treatment. In addition, they highlight the need for discourse and consensus development on the role of social factors in clinical decisionmaking. Dozens of empirical studies have documented significant and widespread racial/ethnic disparities in health care, 1 – 3 and the most heavily documented disparities involve treatment for coronary artery disease. 4 – 24 While insurance status, site of care, and patient preferences account for a portion of overall racial/ethnic variations in care, significant and substantial effects persist independent of these factors. 12 , 25 – 28 The lack of evidence supporting other causal pathways has led to an increased focus on the role of provider behavior. As a result, there is a growing body of evidence suggesting that provider behavior and decisionmaking contribute significantly to racial/ethnic disparities in care 9 , 25 , 29 – 37 (see van Ryn 38 for a review). However, little is known about why patient race or ethnicity influences the clinical decisionmaking process, and thus, there is an inadequate evidence base for guiding intervention priorities and strategies. One approach to understanding the processes by which patient race/ethnicity influences provider decisionmaking can be guided by the extensive amount of social psychological research demonstrating how unconscious stereotypes may lead to bias even among well-intentioned, egalitarian people. 2 , 38 – 40 This evidence suggests that the effects of race/ethnicity on provider behavior may be mediated by unconscious stereotypes or beliefs. In other words, providers’ beliefs about patients may vary according to patients’ race/ethnicity, and these beliefs, in turn, may influence their behavior and decisionmaking. We tested this hypothesis regarding predictors of physician recommendations using a data set that included medical record and provider survey data collected from coronary artery disease patients who had an angiogram performed at one of 8 New York hospitals. Understanding provider recommendations is essential for understanding disparities in care, given that previous published results from the present data set indicate that such recommendations are the proximal cause of almost all observed disparities in receipt of coronary artery bypass graft surgery (CABG). 30 We examined the factors associated with provider recommendations for CABG among the subset of patients who were appropriate candidates for this procedure but not for other aggressive treatments. The data used in this study had unique advantages in that they included provider survey information on the postangiogram encounter at which a treatment determination was made. In their survey responses, providers reported on their recommendations and rated patients on a number of social and behavior characteristics. Previous analyses of the dataset used in the present study revealed that physicians’ perceptions of patients on these measures varied according to patient race, independent of patient age, gender, race, frailty/sickness, mental health status, mastery, and social assertiveness and physician characteristics. Specifically, physicians rated non-White patients as less likely than their White counterparts to participate in cardiac rehabilitation, to desire a physically active lifestyle, and to have a sufficient amount of social support and more likely to be non-adherent and to abuse drugs. 39 In another report involving the present data, we found that patients who had already been rated either as appropriate candidates for CABG or as patients for whom CABG was necessary were more likely to undergo CABG if they had specific clinical characteristics (left main coronary artery disease, 3-vessel disease, and older age). 30 This set of findings suggests the possibility that providers overapply certain clinical characteristics when making treatment recommendations. If these characteristics are also associated with patient race/ethnicity, they may mediate a portion of the observed effect of patient race/ethnicity on provider recommendations. The present data provided an opportunity for a meaningful examination, after control for physician characteristics, patient clinical characteristics, and insurance status, of the degree to which perceptions of patients mediate the observed relationship between patient race/ethnicity and provider recommendations for CABG among patients who are appropriate candidates for the procedure.
