PATIENT ATTITUDES REGARDING HEALTHCARE UTILIZATION AND REFERRAL

6 Dec
2009

PATIENT ATTITUDES REGARDING HEALTHCARE UTILIZATION AND REFERRAL

INTRODUCTION

Significant advances have been made in facilitating health and in preventing disease. Despite medical advances that have resulted in increased longevity for Americans, there are data that contin­ue to suggest that the overall health for racial and ethnic minorities is poorer than that for Caucasian Americans. Emerging studies continue to document disturbing differences in health, disease severity, quality of life, and quality of medical care received based upon the patient’s gender, race, ethnicity, and social stratification. Racial disparities in healthcare have been attributed to biological and historical factors (e.g., segregation, discrimination, lack of trust in the healthcare delivery system) as well as socioeconomic and cultural factors. Differences have also been attributed to variability in physician attitudes and knowledge as well as in healthcare insurance coverage, access, and utilization.  Ineffective communication also remains an important contributing factor to poor-quality healthcare. These patient, healthcare system, and healthcare provider factors contribute to vari­ability in treatment response. However, the implications of these factors in a chronic pain population have not been well elucidated.

There is increasing concern that racial and ethnic minorities receive lower-quality healthcare services when compared to Caucasian Americans. Racial and ethnic disparities in healthcare services have largely been studied, HIV (is used for treating HIV infection in some patients when used in combination with certain other medicines), cancer, diabetes, surgical, and mental healthcare. Although chronic pain (i.e., non-cancer, chronic nonmalignant, chronic benign pain) impacts the overall health and well-being of greater than 65 million Americans and is the most frequent reason for consultation with a physician, few studies have attempted to examine healthcare disparities in a racially and ethnically diverse chronic pain population. African Americans may receive lesser acute, chronic, and cancer pain care than Caucasian Americans. Clear differences in the ability to access progressive medical procedures have been demonstrated by race and ethnicity. Differential healthcare utilization may be due to differential access and quality of care.

African Americans are more likely to be diagnosed at a younger age with a medical condition (e.g., osteoarthritis, hypertension) than Caucasian Americans. They are also disproportionately diagnosed with more severe and debilitating forms of these conditions. The high likelihood of manual labor jobs in African Americans makes them more susceptible to knee trauma and osteoarthritis. The literature shows that African Americans underutilize medical services, even when formal healthcare services are available. The first National Health and Nutrition Examination (NHANES) from 1984 to 1988 revealed that African-American men were three times less likely to receive a total knee arthroplasty compared to Caucasian American men—which does not reflect the high prevalence or increased severity of knee osteoarthritis in this population. Many studies have shown that racial and ethnic minority Americans have fewer visits to primary healthcare providers, are referred less often for specialty care, and have lower rates of diagnostic and screening tests as well as less preventive care for illnesses when compared to Caucasian Americans.

Healthcare utilization is also related to patient satisfaction and patient-physician communication. Cleeland found that racial and ethnic minority persons were at risk for the undertreatment of pain and speculated that communication problems contributed to their problems. Wilson reported that many African Americans are dissatisfied with their healthcare providers. Furthermore, African-American patients reported that their healthcare providers did not inquire about their pain experience, provide information on how long it would take for pain medications to work, discuss test or examination findings, or explain the seriousness of the illness or injury. Similarly, Bernabei showed that the pain assessment and treatment provided for elderly African Americans living in nursing homes was less when compared to elderly Caucasian Americans.

Financial access, health insurance coverage, and physical access directly impact healthcare utilization. The differential use of health services based upon race may be due to differential access. Previous studies have reported that poor and uninsured African Americans were less likely to seek emergency room care even when in pain. Longer delays in seeking healthcare result in poorer outcomes. A study by Todd, et al. revealed that African Americans were less likely to receive analgesics for long-bone fractures in emergency rooms than similarly injured Caucasian-American patients. Lower healthcare utilization rates among African Americans may reflect the emotional and physical attachment some may have with informal institutions (e.g., church) for their mental and physical health needs. However, no study has previously examined healthcare access and utilization patterns in a racially and ethnically diverse chronic pain population.
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New evidence suggests that chronic pain may differentially affect the overall health of African Americans when compared to Caucasian Americans. Healthcare access, utilization, and referral patterns in chronic pain patients from diverse ethnic backgrounds are poorly understood. We hypothesized that the attitudes as well as the chronic pain and healthcare experiences among African Americans differed from Caucasian Americans. More specifically, we speculated that African Americans have less access and different utilization patterns for pain management services when compared to Caucasian Americans. This study was designed to determine whether African Americans differ from Caucasian Americans in their: 1) healthcare utilization, 2) sources of healthcare, 3) access to pain treatment, 4) attitudes and perceptions regarding pain management, and 5) referral patterns.

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