One in Five Patients Report Discrimination by Providers

Norra MacReady

December 18, 2017

Discrimination against patients by healthcare providers on the basis of race, sex, income, or other attributes is still surprisingly common, according to the findings of a study.

In a nationally representative sample of adults aged 54 years or older, the researchers found that between 2008 and 2014, nearly one in five participants reported experiencing some form of healthcare discrimination, defined as "differential treatment stemming from negative attitudes, beliefs, and judgments about members of a socially defined group."

Thu T. Nguyen, ScD, from the Department of Epidemiology & Biostatistics, University of California, San Francisco, and colleagues report their findings in an article published online December 15 in the Journal of General Internal Medicine.

Reports of discrimination declined in frequency during the study period, but nevertheless, the findings "highlight the critical importance of monitoring trends in reports of discrimination in health care to advance equity in health care," the authors write.

Negative interactions with healthcare providers can reduce one's engagement with the medical care system, which may have serious consequences, particularly for patients such as the ones included in this study, all of whom had chronic conditions including hypertension, diabetes, cancer, lung disease, heart conditions, or stroke, the researchers explain.

They cite data from a 2003 report by the Institute of Medicine showing that prejudice or bias by healthcare providers contributes to racial and ethnic disparities in healthcare. If patients perceive they are being treated unfairly, "that could negatively affect their experience with their providers, their willingness to go to their providers, and their adherence with their treatment," Dr Nguyen said in a news release.

Since the IOM report was published, medical schools have developed new curricula designed to reduce inequality in healthcare, but little is known about the effectiveness of these efforts.

The investigators used data from the Health and Retirement Study, a nationally representative study of adults aged 54 years or older, to examine the frequency of patient-reported discrimination over time among people with chronic disease. The study enrolls a new cohort every 6 years, with follow-up questionnaires administered every 2 years after enrollment.

The questionnaire included questions about patients' perceptions of discrimination from 2008 to 2014. They were drawn from the Everyday Discrimination Scale (short version) and included items on how frequently individuals received poorer service from physicians or hospitals compared with other people. Follow-up questions explored the respondents' opinions about possible reasons for the discrimination.

This analysis included data on 13,897 individuals and a total of 21,078 reports of discrimination. The participants had a mean age of 69 years. The percentage of white, black, and Hispanic patients ranged from 79.4% to 82.3%, 9.0% to 9.8%, and 6.2% to 7.7%, respectively, depending on the year.

In 2008, 27% of black patients reported experiencing some form of discrimination by healthcare providers, but this declined to 21% in 2010 and to 20% in 2014. In contrast, discrimination was reported by 18% of white participants in 2008 and 17% in 2014, with little change between years. Approximately 15% of Hispanic patients reported discrimination in 2008; this rose to approximately 18% by 2012 but returned to its original level in 2014.

In the 2008 survey, 48% of black patients who reported discrimination cited race or ancestry as the reason, followed by age (29%) and financial status (20%). Among whites, 29% gave age as the reason for discrimination, followed by weight or other physical appearance characteristic (16%), and sex or financial status (10% for both). Hispanics most frequently reported age discrimination (27%), followed by race or ancestry (23%) and weight or physical appearance and financial status (14% for both).

Overall, the black/white difference in reported healthcare discrimination fell from 8.2% (95% confidence interval, 4.5% - 12.0%) in 2008 to 2.5% (95% confidence interval, −1.1% to 6.0%) in 2014. This trend in changes was statistically significant among black (P = .01) but not white (P = .24) or Hispanic (P = .91) patients.

Greater wealth was associated with fewer reports of discrimination by whites, but not by blacks, which suggests that when it came to experiences with the healthcare system, improved financial status "had no benefit for blacks," the authors add.

Along with findings from previous studies, these results should serve as a warning to providers "that a large fraction of patients will have experienced some form of discrimination in a health care setting, which may impact satisfaction with and utilization of care and patient-provider relationships more broadly," the authors conclude. "Simply recognizing how common these experiences are for patients may help clinicians provide more appropriate, patient-centered care." Eliminating discrimination entirely, however, will require "ongoing efforts."

The authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online December 15, 2017. Abstract

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