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© 2005 American Public Health Association
DOI: 10.2105/AJPH.2004.046177
RESEARCH AND PRACTICE |
Thomas R. Konrad and Timothy S. Carey are with the Cecil G. Sheps Center for Health Services Research at the University of North Carolina, Chapel Hill. Daniel L. Howard is with Shaw University, Raleigh, NC. Lloyd J. Edwards and Anastasia Ivanova are with the Department of Biostatistics, School of Public Health, University of North Carolina, Chapel Hill.
Correspondence: Requests for reprints should be sent to Thomas R. Konrad, PhD, Cecil G. Sheps Center for Health Services Research, UNC-CH, 725 MLK Blvd/Airport Rd CB 7590, Chapel Hill, NC 27599-7590 (e-mail: bob_konrad{at}unc.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSReferences |
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To assess the effects of physician–patient racial concordance and continuity of care on hypertension outcomes, we described patterns of care for hypertension; we used cross-tabulations and repeated measures (generalized estimating equations) analyses with panel survey data from elderly persons interviewed and examined in 1987 and 1990. Continuity of care was associated with recognition of hypertension, receipt of medication, and lower incidence of undetected hypertension. Physician race had little effect, but continuity is important for successful management of hypertension in older persons.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSReferences |
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Despite progress in hypertension management, African American persons1,2 have lower rates of recognition, treatment, and control of hypertension than do White persons.3,4 Elderly persons have similar hypertension treatment rates but poorer control than do younger persons. Demographic dissimilarities underlie doctor–patient communication difficulties affecting health outcomes,5–11 whereas patient–provider racial concordance correlates with patient participation in care, satisfaction, and treatment adherence.12–19 Stability in doctor–patient relationships correlates with patient satisfaction and access to care.1 This study assessed how physician–patient continuity and racial concordance5,20 affect hypertension diagnosis and medication use in White and African American elderly patients.
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METHODS |
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The Piedmont Health Survey of the Elderly conducted in-home interviews and recorded blood pressure readings in 4162 persons aged 65 years or older in 1986 to 1987 (approximately 80% response) and followed up 3536 surviving older persons in 1990.21,22 Our subsample (1834 African American individuals; 1533 White individuals) excluded respondents who lacked critical survey responses (n = 25) or who named unidentifiable, out-of-state, or nonphysician practitioners (n = 45) or non-White, non–African American physicians (n = 99).
Named physicians were matched to licensure files. Anonymous physicians’ race, age, gender, graduation year, and specialty were linked to the Piedmont Health Survey of the Elderly files that had respondents’ care site location, demographics, trichotomized self-reported health ("poor" or "fair" vs combined "excellent" and "good"), chronic illness indices23 (hypertension, diabetes, heart disease, stroke, cancer), and dichotomized Katz scale.24 Physician affiliation was (1) discontinuous (naming no physician at least once), (2) switching physicians (naming different physicians at each survey), or (3) continuous (naming same physician both times). A 4-valued racial concordance measure compared physician with patient race. Methods for measuring hypertension-related outcomes are described in Table 1
.25
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Descriptive comparisons used
2 and t tests. For each repeated outcome, a multivariate linear model was fit with generalized estimating equations, allowing assessment of the effects of multiple predictors across time for each analysis.26,27 Initial analyses tested associations between outcomes and respondent–physician racial dyads and continuity of care; subsequent models controlled for respondent and physician characteristics. Analyses of 2-way interactions between care source, racial dyad, and continuity of care aimed to detect subgroup effects. Subject clustering within physicians was assessed by alternating logistic regression28 to detect patterns of physician clustering of repeated binary outcomes within subjects. Clustering within physicians showed weak or no statistical significance and was not reported. We incorporated Piedmont Health Survey of the Elderly weights into multivariate analyses when possible, but weighting had to include respondents not meeting inclusion criteria. Some strata lacked variation in physician characteristics or had only 1 physician yielding apparent "missing" cases in analyses, affecting more than 31% of the baseline sample. Hence we report full final models run without survey weights; we adjusted for sample design; showed adjusted odds ratios, significance levels, and confidence intervals in a table; and used footnotes for significant covariates. Given numerous statistical tests, P<.01 was considered statistically significant, with .01<P<.05 considered a trend. We used SAS software (SAS Institute Inc, Cary, NC).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSReferences |
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Descriptive
The cohort size declined mostly through mortality (Table 1
). Surviving respondents lost spouses; had higher income, better health status, and higher illness scores; and had more nursing home use and functional declines than they did at baseline. More older persons reported regular care sources in 1990; fewer named local private physicians who were younger and trained more recently than 1987. More than 10% named no physician at either survey; 24% named none at 1 survey. Twenty-five percent switched physicians; 38% had the same physician each time. African American physician–patient dyads decreased over time, replaced by White physician–African American patient dyads. Severe hypertension was comparable at each survey. No racial differences were evident in age, gender, employment, or disease severity. Fewer African American individuals were married, and, as a group, they had less education, income, and private insurance and more Medicaid. Self-reported health improved, whereas impairment increased for both groups, but racial disparities persisted. Racial groups had parity in "usual source of care" in 1990, but White patients were more likely seeing nearby private physicians; public sources cared for 1 in 3 African American patients and only 1 in 10 White patients. More African American individuals than White individuals lacked regular physicians at both surveys (14.9% vs 5.5%) or named a physician only once (27.5% vs 20.3%). Conversely, more White patients than African American patients had the same physician across surveys (46.7% vs 30.4%). More African American persons reported that a physician had told them they had high blood pressure. Adverse racial differences were largest for severe hypertension, widening between surveys.
Multivariate Analyses
Table 2 shows no significant effects on measured hypertension. There was a tendency for those with discontinuity in care to have had undetected hypertension more often than did those with continuity of care. Compared with White patients with White physicians, African American patients had a lower incidence of undetected hypertension (and of severe hypertension) regardless of physician race. Elderly persons with discontinuous care were more likely to have undetected severe hypertension, but those naming generalist physicians also may have been at risk for having severe hypertension previously undetected. Those who lacked or had switched physicians received fewer hypertension diagnoses and, if diagnosed, took fewer medications compared with those keeping the same physician.
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Interaction tests suggested that African American respondents who switched physicians may have been more likely to be taking hypertension medications if their new physician was White (P< .02). African American patients whose usual care sources were public clinics and who had African American physicians may have been more likely to have been taking hypertension medications than were African American patients using White physicians or private practitioners (P< .03). Those experiencing discontinuity in physician care and whose usual care sources were public clinics were more likely to have been taking medication (P< .001) than were those who had discontinuous care but from a private practitioner.
Conclusion
Unlike cross-sectional, retrospectively self-reported "usual person and place" surveys, we measured longitudinal patient–physician relationships with 2 temporally separated respondent reports, minimizing error in physician characteristics by combining survey and license data. Study limitations include small numbers in one southern state, which omitted non–African American, non-White physicians and patients. Cumulative reduction in cases for multivariate analyses came from a few missing values in many predictors.
Consistent with other chronic disease studies,29 continuity of care entailed better outcomes. Ongoing physician affiliation improved hypertension detection and medication use once diagnosed. Rates of detection in individuals changing physicians sometimes were midway between those without physicians and those keeping the same physician. African American individuals’ elevated hypertension diagnosis risk was unaffected by physicians’ race, suggesting widespread awareness of African American persons’ worse cardiovascular disease prognoses.4,30 African American patients had a lower risk of having undetected severe (stage 2) hypertension, but elderly patients lacking physicians had a higher hypertension risk. Patient–physician racial concordance effects seemed contextually conditioned (e.g., African American patients using public sources of care may use medication more often if their physician is African American, whereas African American patients who switched physicians may use medication more often if their new physician is White).
Regular access to a usual care source and sustained affiliation with a physician can improve the management of hypertension in older African American and White patients. Because African American Medicare beneficiaries are cared for by a subset of African American physicians often in challenging practice situations,31 better understanding of hypertension care may require more longitudinal study of physician availability and the dynamics of physician selection in addition to racial concordance and continuity of care.
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Acknowledgments |
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Original data collection was sponsored by the Established Populations for Epidemiologic Studies of the Elderly, conducted by the Duke University Center for Aging and Human Development (contract no. N01-AG-12102 and grant no. R01 AG 12765, National Institute on Aging). Analyses were supported by the Agency for Health Care Research and Quality’s Center of Excellence on Overcoming Racial Health Disparities at the Cecil G. Sheps Center for Health Services Research (PO1 HS10861). This study was also supported, in part, by the National Center on Minority Health and Health Disparities (1 P60 MD00239 and 1 R24 MD000167) and the Agency for Health Care Research and Quality (1 R24 HS13353).
Physician data were extracted by the North Carolina Health Professions Data System with the permission of the North Carolina Medical Board.
The authors express their appreciation to Carol Porter for programming assistance and to Gerda Fillen-baum and Donald Pathman, who provided important information for preparation of this brief. Special thanks to Larry Logan and Donna Curasi for editorial assistance.
Human Participant Protection
The University of North Carolina Committee on the Protection of Human Subjects approved the research.
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Footnotes |
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Peer Reviewed
Contributors
T. R. Konrad and D. L. Howard originated the study. T. R. Konrad supervised the creation of the databases and participated in all aspects of the study design, analysis, interpretation of results, and writing of the brief. D. L. Howard reviewed the literature, developed the conceptual framework, wrote initial drafts, and reviewed subsequent drafts of the brief. L. J. Edwards contributed to the study design, initiated and conducted the statistical analysis, contributed to the writing of the brief, and reviewed drafts of the brief. A. Ivanova reviewed the databases and contributed to the study design and analysis. T. S. Carey contributed to the writing of the brief and reviewed drafts of the brief.
Accepted for publication June 3, 2005.
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