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

16 Oct
2009

Population
Participants selected for this study were AfricanAmerican and white male patients who participated in a previous VA-funded study on ethnic/cultural variations in the management of OA. Participants were identified from a list of scheduled primary care visits at VA outpatient clinics. The study staff approached all the patients 50 years of age or older during their routine primary care clinic visit at the Louis Stokes Cleveland VA Medical Center in Cleveland, OH between May 1997 to March 2000. The Louis Stokes Cleveland VA Medical Center is a tertiary care VA medical hospital with primary affiliation with Case Western Reserve University School of Medicine, Cleveland. They were asked a series of questions pertaining to the presence, duration and severity of knee and hip pain, using questions similar to those included in the Arthritis Supplement National Health and Nutrition Examination Survey I (NHANES I).

These questions were:

1) Have you ever had pain in and around your knee and hip on most days for at least one month?

2) During the past month, have you had pain in the knee when walking or standing at least half of the day?

Affirmative answers to both questions indicated knee and hip pain consistent with the presence of symptomatic OA. Patients considered eligible for study inclusion had to be >50 years of age and had to have moderate-to-severe pain based upon a score of >5 on the Lequesne Osteoarthritis Severity Index (described below). Patients who already had knee and hip replacement were excluded. Between May 1997 and March 2000, 1,351 patients were approached and screened for eligibility. Of these, 57% met the inclusion criteria, and 95% of eligible patients agreed to participate in the study. Only 600 were invited to complete all the components of the study. Data from four patients were incomplete and not included in the analysis, leaving a sample of 596 patients for analysis. The study was approved by the hospital’sData Collection Demographic information: Baseline demographic information was obtained by interviewers using field-tested questionnaires. Pertinent information included age, educational level, employment status, annual household income and marital status. Race/ethnicity was the primary independent variable of interest. Information on race/ethnicity was obtained through patient self-report.
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Study Outcome Measures
Patient confidence and satisfaction with knee and hip pain care: To assess participant perceptions regarding the quality of and satisfaction with the participant-physician relationship, we asked participants to respond to the following items: 1) Describe the relationship you have with your primary physician (five-point categorical response scale: “excellent” to “poor”); 2) Do you have confidence in your primary care provider (five-point categorical response scale: “very much” to “not at all”); and 3) How satisfied are you with the care this doctor provides for you (five-point categorical response scale: “very satisfied” to “very dissatisfied”)? Responses were dichotomized for this analysis after reviewing the distribution of the responses. The first question was dichotomized as “excellent” versus ” poor, fair, good or very good.” The second question was dichotomized as “quite a bit or very much” versus “not at all, a little or somewhat.” The third question was dichotomized as “very satisfied or somewhat satisfied” versus “somewhat dissatisfied, dissatisfied or very dissatisfied.”

Patient perceptions regarding access to care: To assess participant perceptions regarding access to care, we asked the following questions: 1) Overall, how difficult is it for you to get medical care when you need it; and 2) How difficult would it be for you to get medical care outside of the VA? Responses ranged from “impossible” to “not at all difficult” on a five-point categorical scale for both questions. Responses to these questions were also dichotomized for this analysis. These questions were dichotomized as “not too difficult or not at all difficult” versus “extremely difficult, very difficult or somewhat difficult.”
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Additional non-VA insurance: We assessed the proportion of patients with additional non-VA insurance by asking the following question: Besides your current insurance, which type(s) of additional insurance do you have? The participant then completed a seven-item checklist of multiple health insurance programs, indicating if the participant was a beneficiary of that additional insurance option or not. The seven choices were: Medicaid, Medicare, Medigap or insurance that pays what Medicare does not, private or group insurance, health maintenance organization (HMO), other unlisted insurance or no additional insurance. Each item was coded dichotomously yes/no, and proportions were based on positive responses.

Receipt of referrals for specialist care: To assess for possible differences in the proportion of participants that received referrals for specialist (rheumatology and orthopedics) care from their primary care provider, we examined medical record data for each participant to measure the frequencies of referrals requested by the primary care provider for a rheumatology or orthopedic surgery evaluation.
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Study Covariates
The Lequesne Index: The Lequesne Osteoarthritis Severity Index has high internal consistency (Cronbach’s a=0.84) that has been validated and used in other studies. Hip pain severity is rated on a scale ranging from 0 to 24; knee pain severity is rated from 0 to 22. Scores >5 are considered to indicate moderate-to-severe pain.

Kellgren/Lawrence (K/L) Scale: Radiographic evaluation of the symptomatic joint was obtained if it had not been performed in the past year. To confirm the diagnosis of joint OA, all radiographs were graded using the K/L scale. This scale has been validated and is used extensively in clinical research.

Charlson Comorbidity Index: We used the Charlson Comorbidity Index to assess for the presence of comorbid conditions, such as heart disease, cancer or diabetes. This medical record-derived scale is based upon the mean number of comorbid diseases per patient; scores range from 0 to 13.

Geriatric Depression Scale (GDS): The GDS is a validated 15-item scale used to screen for depressive symptoms in the elderly. Scores of 0—4 are considered normal; scores of 5-9 indicate mild depression; scores of 10-15 indicate moderate-to-severe depression. This scale was used to assess the presence of comorbid depression in our study population.
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Western Ontario MacMaster Index (WOM-AC): The WOMAC index is a reliable (Cronbach’s a >0.80) and valid scale specifically designed to assess lower-extremity pain and function in OA. The scale ranges from 0 to 100, and patients with scores >39 are considered candidates for joint replacement.

Statistical Analysis
We conducted baseline comparisons between white and African-American participants using Chi-square for categorical variables, and t test for continuous, normally distributed variables. White and African-American participants were compared with respect to demographics, disease severity, radiographic staging of disease, presence of depression and presence of comor bid states. Statistical significance was set at an oc< 0.05. Bivariate associations between race and the main outcome measures were examined using either Chi-square or t tests, depending on the nature and distribution of the data collected for each variable. Variables that approached statistical significance were further analyzed through a series of logistic regression models examining the association of the independent variable of race with each outcome variable. These logistic regression models included adjusted age, income, educational level, Charlson Comorbidity Index score, OA severity (WOMAC score) and radiographic stage of disease (K/L score). Prior to multivariate analysis, each outcome variable was dichotomized after careful consideration and inspection of the distribution of responses given for each item. generic avodart

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