Socioeconomic and racial/ethnic differences in the discussion of cancer screening: "between-" versus "within-" physician differences
Socioeconomic and racial/ethnic differences in the discussion of cancer screening: "between-" versus "within-" physician differences
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DOI：
10.1111/j.1475-6773.2006.00638.x
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发表时间：
2007-06-01
影响因子：
3.4
通讯作者：
Escarce, Jose J.
中科院分区：
文献类型：
--
作者：
Bao, Yuhua;Fox, Sarah A.;Escarce, Jose J.
Objective.确定患者和他/她的初级保健医生之间癌症筛查讨论中的社会经济和种族/民族差异在多大程度上是由于“医生内”差异（患者由同一医生进行不同治疗的事实）与“医生间”差异（他们由不同的医生组进行治疗）。我们使用的数据来自医疗护理交流（CMC）研究系列的两项社区试验的基线患者和医生调查。这两项研究结合起来提供了一个分析样本，5,978名年龄在50-80岁之间的患者，这些患者来自191名在南加州执业的初级保健医生。我们感兴趣的主要结果是医生是否曾与患者谈论过粪便潜血试验（FOBT;用于结直肠癌筛查）、乳房X线检查（用于乳腺癌筛查，仅限女性患者）和前列腺特异性抗原试验（PSA，仅限男性患者）。我们考虑了五个种族/民族群体：非西班牙裔白色，非西班牙裔黑人，西班牙裔，亚洲人和其他种族/民族。我们通过收入和教育来衡量社会经济地位。对于每种类型的癌症筛查讨论，我们首先估计一个概率单位模型，其中包括患者特征作为唯一的协变量，以评估总体差异。然后，我们添加医生固定效应，以获得“内”与“间”医生差异的估计。在所有三种类型的癌症筛查的讨论中有一个很强的教育梯度，大多数教育差异出现在医生内部。收入差异在不同的筛查方法中不太一致，但似乎主要是因为“医生之间”的差异。与白人相比，亚洲人接受FOBT和PSA讨论的可能性要小得多，这些差异主要是“医生内”差异。黑人女性患者，然而，更有可能，与白人相比，由同一个医生治疗，有讨论乳房X光检查与他们的医生。癌症筛查讨论中的差异沿着患者SES的不同维度可能是由于非常不同的机制而产生的，因此需要联合干预。医生需要意识到患者教育在癌症筛查临床沟通中的持续差异，并根据低教育程度患者的需求调整他们的努力。针对低收入社区执业医生的质量改进工作也可能有效地解决患者收入在癌症筛查沟通方面的差异。
Objective. To determine the extent to which socioeconomic and racial/ethnic differences in cancer screening discussion between a patient and his/her primary care physician are due to "within-physician" differences (the fact that patients were treated differently by the same physicians) versus "between-physician" differences (that they were treated by a different group of physicians).Data Sources. We use data from the baseline patient and physician surveys of two community trials from the Communication in Medical Care (CMC) research series. The two studies combined provide an analysis sample of 5,978 patients ages 50-80 nested within 191 primary care physicians who practiced throughout Southern California.Study Design. Our main outcomes of interest are whether the physician has ever talked to the patient about fecal occult blood test (FOBT; for colorectal cancer screening), mammogram (for breast cancer screening, female patients only) and the prostate-specific antigen test (PSA, male patients only). We consider five racial/ethnic groups: non-Hispanic white, non-Hispanic black, Hispanic, Asian, and other race/ethnicity. We measure socioeconomic status by both income and education. For each type of cancer screening discussion, we first estimate a probit model that includes patient characteristics as the only covariates to assess the overall differences. We then add physician fixed effects to derive estimates of "within-" versus "between-" physician differences.Principal Findings. There was a strong education gradient in the discussion of all three types of cancer screening and most of the education differences arose within physicians. Disparities by income were less consistent across different screening methods, but seemed to have arisen mainly because of "between-physician" differences. Asians were much less likely, compared with whites, to have received discussion about FOBT and PSA and these differences were mainly "within-physician" differences. Black female patients, however, were much more likely, compared with whites treated by the same physicians, to have discussed mammogram with their physicians.Conclusions. Differences in cancer screening discussion along the different dimensions of patient SES may have arisen because of very different mechanisms and therefore call for a combination of interventions. Physicians need to be aware of the persistent disparities by patient education in clinical communication regarding cancer screening and tailor their efforts to the needs of low-education patients. Quality-improvement efforts targeted at physicians practicing in low-income communities may also be effective in addressing disparities in cancer screening communication by patient income.