Patient Perceptions of Access to Care and Referrals to Specialists: DISCUSSION

18 Oct
2009

In this sample of nearly 600 elderly male veterans with moderate-to-severe OA of the hip and/or knee, we found that African-American patients reported less non-VA insurance coverage than white patients. White patients were more likely than African-American patients to report that it was difficult getting medical care when they needed it. Differences between the two groups in their perceptions regarding satisfaction with and confidence in the primary physician were not significant after adjusting for covariates. Finally, African-American and white patients with knee and hip OA were equally likely to be referred for specialist care, though a nearly significant trend favoring whites existed concerning referral rates to an orthopedist.

Our finding regarding African-American and white differences in having additional (non-VA) insurance is consistent with previous studies reporting racial differences in insurance coverage. A number of investigators have reported that whites are more likely to have health insurance. More specifically, it was found that blacks and Hispanics are both less likely than whites to be privately insured and more likely to be publicly insured. Additional studies report that the extent of insurance coverage is associated with differences in medical resource use among older adults. Dunlop and colleagues found that those with supplemental private or government health insurance were more likely to undergo joint replacement than those with Medicare alone. However, this effect only partially contributed to these differences. Another recognized source of variation lies in physician practice styles. In a recent report of 720 physicians in the United States, 31%» reported not offering care to patients because of health plan coverage rules “at least sometimes.” Variation in physician practices based upon insurance status and patient socioeconomic status continues to deserve attention and has been reported in other studies. generic finasteride

Our findings indicate that referral rates to specialty services in one VA center for the treatment of knee and hip OA were similar. Racial disparities in referral rates for other aspects of medical services have been reported previously. Ashton and colleagues have shown that African Americans and Latinos use services that require a doctor’s order at lower rates than do whites. Petersen and colleagues also reported a relationship between race and cardiac procedure utilization rates in the VA system. However, our study is one of the first studies to investigate potential differences in the receipt of referrals to specialty services in the treatment of moderate-to-severe OA of the knee and hip. If the proportions of those who received referrals for specialist care are similar based on race as shown in our findings, then the causes of the observed difference in procedure utilization rates may lie elsewhere in the path to receipt of joint replacement surgery. We note that the trend in differences in the receipt of referrals for orthopedist care between African Americans and whites approaches statistical significance. Therefore, differences in referral to orthopedics as a factor in this disparity cannot be ruled out by our data. The reasons for this are multifactorial. First, we must look again at patient-based factors, such as beliefs regarding the disease and beliefs regarding the potential treatment. Previous studies have shown that there are important differences in treatment preferences and expectations between African Americans and whites. The second possibility lies in the practice of the care provider. Studies have shown that patient-based factors, such as insurance coverage, significantly influence provider practice patterns. The fact that this difference may exist in an otherwise equal-access setting raises the need for additional study of provider-based factors. Our study analysis did not address these potential factors.

Although whites reported more access to additional non-VA insurance compared to African Americans, they paradoxically reported not getting access to medical care when they need it. The source of this inconsistency is uncertain. One possible explanation is that the patients may have misinterpreted the question addressing this factor. One may have responded to the ease of transport to the specific site of care, which is located in urban predominantly African-American neighborhood. Significant numbers of whites receiving care at this medical center travel from neighboring suburbs and rural communities. It is conceivable that the lack of access expressed by white patients is a reflection of this physical access barrier. discount flomax

Overall, the results of this study advance the research on understanding why African-American and white potential candidates for knee and hip joint replacement differ in their utilization of this effective treatment option. Previous work in this area has shown that African-American and white patients who are candidates for these procedures differ in their cultural perceptions about the efficacy and usefulness of this treatment option. They also vary in terms of their awareness and understanding of the benefits/risks of this treatment option. Little is known regarding how provider- and system-level factors, such as those examined by this study, impact this disparity. Our study attempts to expand the inquiry by examining patient perceptions and experiences regarding provider and system factors that could contribute to the observed racial/ethnic variations in the receipt of joint replacement.

There are important limitations to consider when interpreting our results. First, this is an observational cross-sectional study of male African-American and white veterans, therefore, findings may not be applicable to women and to other minorities, and changes in patient perceptions and experiences in the healthcare system may change over time. Second, though this study reports differences between African Americans and whites, these differences cannot be linked directly to the observed disparity in knee and hip replacement utilization. More work is needed to establish causal inference. Third, this study was conducted in one VA medical center in one city; therefore, our findings may differ depending on medical care site and study location. Finally, this study involved participants recruited from a primary care setting. Patients receiving care primarily in specialty clinics may have been excluded from our study. However, the potential bias introduced by selecting this population of patients with similar comorbidities and severity of illness is minimized. singulair medication

In summary, we have found that African-American and white potential candidates for knee and hip joint replacement vary in their perceptions of access to medical care and experiences of the healthcare system. More research is needed to investigate specific system- and provider-based factors that may explain this disparity. Examples include patient-provider communication, trust and decision-making on joint replacement surgery. This will improve our understanding of the causes for the observed disparities and will guide future interventions aimed at alleviating the growing racial/ethnic disparities in the use of joint replacement—an effective treatment option for end-stage knee and hip OA.

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