Health Disparities

Primary care has been defined as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”¹ Recent work links the strength of primary care health services in industrialized nations with improvements in health indicators.² Most conditions for which health disparities are documented are diagnosed and managed by primary care physicians. In this issue of Journal of General Internal Medicine, five papers provide new insights regarding the role of primary care in the agenda to eliminate racial and ethnic health disparities. They also identify a key role for the patient-physician relationship.

Three studies identify access to outpatient care and use of preventive procedures as ongoing contributors to racial and ethnic health disparities. Bliss et al. use national data to show that fewer blacks and Hispanics than whites receive health care in physicians’ offices, outpatient clinics, and emergency departments.³ They suggest that research and programs aimed at reducing disparities in receipt of care in outpatient settings are needed.

Glazier et al. use geographic methods to understand disparities in mammography use in low-income, high–recent immigration areas in Toronto, Canada.⁴ The authors show that marked variation exists in mammography rates by area. Lowest rates occur in low-income and high–recent immigration areas; spatial patterns show areas with low mammography and low physician visit rates and areas with low mammography and high physician visit rates.

De Alba et al. use data from the 2000 National Health Interview Survey to assess the impact of English language proficiency on Pap smear use among Hispanic women.⁵ After adjusting for confounders, they find that proficient English speakers are more likely to report a Pap smear in the past 3 years than women with low English proficiency.

These three studies suggest that access barriers⁶—personal (e.g., patient knowledge, attitudes, and language), financial (e.g., income), and structural (e.g., availability of appointments)—still need to be addressed among ethnic minorities at community and health system levels. Glazier et al.'s finding of low mammography and high physician visit rate areas also suggests that ethnic minority women from certain neighborhoods may need more attention placed on their interactions with physicians. Future studies might examine in depth the reasons for these findings by exploring primary care physicians’ discussions about screening for breast cancer with low-income, immigrant women. De Alba's study supports the notion that patient-physician communication is an important intervention target for populations with low English proficiency through improved access to language-concordant providers, language training for physicians, and interpreter services, all of which have been linked to improvements in service use, patient satisfaction with interpersonal care, and health status.^7–9

Two studies use data collected at the patient-physician encounter level to examine disparities in care. Barr conducts an analysis to determine whether a patient satisfaction scale is sufficiently sensitive to identify racial and ethnic differences in satisfaction and finds that while there are no differences between ethnic minorities and whites in overall satisfaction, ethnic minority patients (most of whom are Asian in this sample) are less satisfied than whites with their interactions with physicians.¹⁰

Gordon et al. conduct a prospective cohort study of patients in the exercise treadmill or cardiac catheterization laboratories at a Veterans Affairs hospital.¹¹ They show that recommendations for procedures do not differ significantly by patient race, and that while declining angiography or refusing to return for it are slightly more common among African Americans and Hispanics than whites, patients’ decisions to decline recommended invasive cardiac procedures are infrequent and likely explain only a small fraction of racial and ethnic disparities in the use of these procedures.

Both Barr and Gordon et al. suggest that future studies should focus on the role of patient-physician communication. Barr suggests that a closer look at race-discordant patient-physician encounters may help to explain poorer perceptions of physician care by ethnic minorities. Gordon et al.'s study is one of the first to directly observe patient-physician interactions after exercise treadmill tests and cardiac catheterization procedures rather than relying on indirect methods of assessing patient refusals. These two studies add to a body of work that identifies partnership in decision making,¹² rapport-building communication behaviors,¹³ and physician bias¹⁴ as areas ripe for intervention.

The studies in this issue provide additional evidence that disparities in health care exist across conditions and procedures, suggesting that fundamental aspects of health care, such as patient-physician communication, play a role. Strong evidence links patient-centered communication behaviors to patient satisfaction, adherence, continuity of care, and health status.^15,16 The foundation of primary care is a sustained relationship between patients and the clinicians who care for them. In meeting the challenge of racial and ethnic health disparities, primary care clinicians and researchers must keep central the ideal of providing exemplary care to individual patients in the context of their personal circumstances, which include biomedical, psychosocial, and cultural factors.