Assessing the Role of the
Physician and Practice Setting in
Child Health Disparities
Lauren A. Smith1, Andrew Johnson2, Carol J. Simon2
1Boston
University School of Medicine
2Abt Associates and Boston University
School of Public Health
Supported by grants from Agency for Healthcare Research and
Quality, The California Endowment & The Commonwealth Fund
Research Objectives



To examine clinical decision making for
2 pediatric conditions with a high degree
of clinical discretion
To identify any racial/ethnic differences
in clinical decision making
To explore the association of physician
and practice characteristics with
decision making and any disparities
Study Design & Population Studied

Mixed-mode (mail, web) survey




Random sample of 1,500 primary care
physicians from AMA Physician Masterfile
N=771 pediatric providers
5 states: CA, GA, IL, PA, TX
Minority MDs over-sampled




~15% African American and/or Hispanic
Fielded January-May 2007
65% response rate
Practice questions plus clinical vignettes
Survey Data Domains

Practice & patient
characteristics




Location
Payer types
Racial/ethnic
composition of
patient population
Limited English
proficiency

MD characteristics




Race/ethnicity
Gender
Age
Time since
graduation
Race/Ethnicity Variation
in Vignettes
Vignette Name
Race/ethnicity
1a
Elena
Latina
1b
Aisha
African American
1c
Kristen
White
2a
José
Latino
2b
Darnell
African American
2c
Todd
White
Vignette 1


NAME, a previously healthy 13 yo RACE/ETHNICITY
girl, sees you for the evaluation of stomach pain,
headaches and fatigue. Her mother says her
daughter often complains about being sick. She had
been an above-average student, but now gets poor
grads. She often naps during the day and recently
quit the school chorus because she was “too tired”.
She has difficulty sleeping. She denied alcohol or
drug use. Recent medical evaluation, including blood
work was normal. The patient lives with brother and
sister.
PE: Height 50%ile; weight 75%ile, up 8 pounds since
last year. She is quiet during the interview and says
she “feels fine”. The remainder of PE is normal.
Vignette 1 Results by Race
Clinical
management
Total
N=771
%
White
N=260
%
Black
N=251
%
Latino
N=260
%
Dx=adolescent
response very likely
23
25
22
22
Dx=depression very
likely
39
42
36
39
Observe
17
14
16
19
Refer to mental health
provider
70
71
68
70
No medical therapy
81
81
82
80
Start anti-depressant
18
18
16
19
Vignette 1 Results by Practice/Patient
Characteristics
Clinical management
Latino Patients
Black patients
<20% 40% <20%
N=296 N=211 N=466
%
%
%
40%
N=73
%
Dx=adolescent response
very likely
23
27
23
23
Dx=depression very likely
37
40
42
32*
Observe, reassess
16
18
16
19
Refer to mental health
provider
73
67
72
60*
No medical therapy
81
82
82
85
Start anti-depressant
18
15
18
15
Vignette 1 Results by Practice/Patient
Characteristics
Clinical management
LEP Patients
Medicaid patients
<20% 40% <20%
N=463 N=121 N=355
%
%
%
40%
N=225
%
Dx=adolescent response
very likely
21
28*
21
29*
Dx=depression very likely
40
43
40
36
Observe, reassess
14
24*
14
18
Refer to mental health
provider
73
66*
74
64*
No medical therapy
81
88**
84
81
Start anti-depressant
18
13
15
19
Vignette 2



NAME, a 9 yo RACE/ETHNICITY boy, arrives with his
mother for a new patient visit. He was diagnosed
with asthma 2 yrs ago. In the past year, he has had
2 ED visits, 1 hosp, and 1 short course of oral
steroids. He has some wheeze & cough 2-3
times/week and awakes once or twice/month w/
cough. His mother states “it doesn’t seem to bother
him.” He gets albuterol nebs for his coughing &
wheezing episodes.
One older sibling w/ history of wheezing. No drug,
food or seasonal allergies. There is a cat at home.
Mother smokes.
PE: Wt for ht is above 75%ile. No audible wheezing.
Vignette 2 Results by Race
Clinical management
Total
White
Black
N=771 N=260 N=251
%
%
%
Latino
N=260
%
Dx=mild persistent
33
35
30
32
Dx=mod persistent
59
56
61
59
Check peak flow
69
71
67
69
Asthma action plan
88
89
87
88
Refer to asthma specialist
21
20
22
21
Inhaled corticosteroids
seasonally/short period
23
26
23
21
Inhaled corticosteroids
year round
71
72
69
73
Vignette 2 Results by Practice/Patient
Characteristics
Clinical management
Latino Patients
Black patients
<20% 40% <20%
N=296 N=211 N=466
%
%
%
40%
N=73
%
Dx=mild persistent
32
30
32
41*
Dx=mod persistent
60
56
59
58
Check peak flow
65
76*
73
56*
Asthma action plan
84
91*
87
83
Refer to asthma specialist
24
19
23
13**
Inhaled corticosteroids
seasonally/short period
22
21
23
19
Inhaled corticosteroids
year round
73
72
72
73
Vignette 2 Results by Practice/Patient
Characteristics
Clinical management
LEP Patients
Medicaid patients
<20% 40% <20%
N=463 N=121 N=355
%
%
%
40%
N=225
%
Dx=mild persistent
32
35
27
37*
Dx=mod persistent
61
57
64
53*
Check peak flow
65
79*
68
73
Asthma action plan
87
92
85
90**
Refer to asthma specialist
22
20
25
17*
Inhaled corticosteroids
seasonally/short period
23
24
23
21
Inhaled corticosteroids
year round
73
68
74
71
Conclusions




Substantial variation reported in clinical
management of childhood depression and
asthma
No variation noted based on race/ethnicity
of patient in vignette
Practice characteristics associated with
differences in clinical decision making
Physicians who had high proportion of
black patients or Medicaid-insured patients
were less likely to refer to specialists
Limitations



Vignettes may not reflect true decision
making practices
Triggers in vignettes may not have been
sufficient to trigger differences in decision
making
Sample from 5 states may not be
generalizable to all pediatricians