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

17 Oct
2009

Baseline Comparisons

Table 1 summarizes the clinical, demographic and psychosocial characteristics of the comparison groups. The two groups were similar with respect to age, Charlson Comorbidity Index score, Lequesne scores, WOMAC scores and GDS. However, African-American participants, when compared to white participants, reported lower annual household incomes (P<0.01) and were less likely to be employed (P=0.01), married (P<0.01) or educated beyond the high-school level (P<0.01). Radiographic evidence for OA severity measured by K/L score was similar between the two groups (P= 0.08).

Table 1. Sample Demographic, Clinical and Psychosocial Characteristics by Ethnicity (N=596)

Variable                                    African-American

Age (mean years ± SD)                       65 ± 10

White

66 ± 19

P Value

0.50

Education (%) < High-school education High-school diploma > High-school education42.6 46.1 11.329 51.7 19.3

<0.01

Annual Household Income (%)

<$ 10,000

$10,000-14,999

$15,000-29,999

$30,000 and higher

41.4 28.5 20.1 10.020.4 30.6 36.3 12.7

<0.01

Employment Status (% employed)8

15

0.01

Marital Status (% married)39

56

£0.01

Lequesne Severity Score (mean ± SD)*11 ±4

11 ±4

0.22

WOMAC Index Score (mean ± SD)*46 ± 17

45 ± 17

0.32

Kellgren-Lawrence Score* (%) Score = 0 (normal) Score = 1 (minimal) Score = 2 (moderate) Score = 3 (severe)20.6 28.3 29.2 21.920.9 32.6 27.6 18.9

0.08

Geriatric Depression Scale (mean ± SD)4.5 ± 3.4

5 ±3.8

0.07

Charlson Comorbidity Index (mean ± SD)2.3 ±2

2.5 ±2

0.24

* Lequesne Severity Score: Osteoarthritis Severity Measure; WOMAC Index Score: Osteoarthritis Functional Status Measure; Kellgren-Lawrence Score: Radiologic Survey Criteria; WOMAC: Western Ontario MacMaster index; Scores represent mean scores with standard deviations.

Bivariate Analyses

Table 2 lists the bivariate associations of the study outcome variables and the primary predictor (race). Can’t afford your medication? Buy finasteride online

Table 2. Bivariate Associations between the Race/Ethnicity of the Study Participants and the Study Outcome Variables (N=596)

Dichotomized Variable

AA(%)

White (%)

P Value
1) Confidence In and Satisfaction with Care
Quality of relationship with primary physician considered excellent

24.7

36.3

£0.01
Satisfied with primary physician care for knee and hip OA

43.5

56.5

0.18
Expressed confidence in primary physician

75.7

82.6

0.04
2) Perceptions of Access to Care
Getting medical care is difficult

27.9

19.5

0.02
Accessing care outside of the VA is difficult

52.2

52.4

0.95
3) Having Additional Non-VA Insurance
Medicaid

14.0

11.0

>0.05
Medicare

48.0

63.4

£0.01
Medigap

5.5

12.1

<0.01
Private or Group insurance

23.2

14.2

<0.01
HMO

8.1

9.1

0.69
Other insurance

43.9

56.1

0.08
No additional insurance

44.5

28.6

<0.01
4) Receiving Specialty Referrals for Osteoarthritis Treatment
Orthopedic Surgeon

17.4

24.2

0.06
Rheumatologist

44.2

55.8

0.77
Physical therapy service

38.5

32.5

0.14
Pain service

41.3

39.4

0.66
AA: African-American

Confidence in and satisfaction with care: Two of the three items in this domain yielded significant differences between groups. When compared to whites, African Americans were less likely to consider the patient-physician relationship as excellent (24.7% vs. 36.3%, P<0.01). African Americans were also less likely to express confidence in their primary physicians (75.7% vs. 82.6%, P=0.04). generic lexapro

Patient perceptions regarding access to care: A significantly higher proportion of whites than African Americans reported that it was difficult to get medical care when they needed it (27.9% vs. 19.5%, P=0.02). However, perceived difficulty in accessing care outside of the VA was not significantly different between groups (52.4% vs. 52.2%, P=0.95).

Additional non-VA insurance: A significantly higher proportion of African Americans reported not having any additional non-VA insurance (44.5% vs. 28.6%, P<0.01). For example, when compared to whites, African Americans reported significantly lower enrollment in Medicare (48% vs. 63.4%, P<0.01), Medigap (5.5% vs. 12.1%, P=0.01), and private or group insurance (23.2% vs. 14.2%, P=0.01).

Receipt of referrals for specialist care: There were no statistically significant differences in the proportions of those who received referrals between the groups. However, the differences in the proportions that received referrals to orthopedic clinic approached significance, with a greater proportion of white subjects receiving referrals (24.2% vs. 17.4%, P=0.06). seroquel 200 mg

Results from Multivariate Models

From the bivariate analyses reported above, we identified eight items where differences between African Americans and whites were significant or near significant. These were further analyzed using multiple logistic regression models, adjusting for age, income, education level, comorbidity, presence of depressive symptoms, and severity of disease (Table 3). Most of the items belonged to the domain measuring the presence of additional non-VA insurance. Although the proportions of those who received referrals for specialist care were similar for African-American and white patients in this sample, there was a trend favoring white patients with regards to referral to orthopedics for similar indications (P=0.06).
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Table 3. The Crude and Adjusted* Odds Ratios Associations between Participant Race/Ethnicity and Select1 Outcome Variables from Multivariable Regression Models (N=596)

Variable

Unadjusted AA to White OR

Adjusted AA to White OR

P Value

(95% CI)

(95% CI)

No additional health insurance

2.02 (1.32-3.09)

1.93 (1.13-3.28)

0.02

Private or group insurance

0.55 (0.33-0.92)

0.69 (0.40-1.21)

0.19

Medigap insurance

0.39 (0.19-0.83)

0.41 (0.19-0.91)

0.03

Medicare insurance

0.53 (0.36-0.78)

0.48 (0.29-0.79)

<0.01

Difficulty getting medical care

0.57 (0.36-0.91)

0.54 (0.34-O.88)

0.01

Referral to an orthopedic surgeon

0.64 (0.40-1.05)

0.61 (0.36-1.03)

0.07

Quality of relationship with primary physician 0.64 (0.42-0.96)

0.71 (0.47-1.09)

0.12

Confidence in primary physician

0.84 (0.52-1.35)

0.88 (0.53-1.45)

0.61

AA: African-American; OR: Odds Ratio; CI: Confidence interval; * Adjusted for race, age, educational level, income, WOMAC score,

Charlson score and Kellgren-Lawrence score; t Only outcome variables found to be significant or approaching statistical significance

(a<0.05) at the bivariate level are shown.

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