1) How do individual physicians contribute to health care disparities? Thinking about an area of health care of particular interest to you, what research do you think could be done to either understand the effect of individual physicians on health disparities, or to decrease this effect?
Individual physicians bring their own personal experiences and hidden biases to any patient encounter. A few great examples were raised in the Brooks editorial and van Ryn paper: a language barrier between provider and patient may lead to a more cursory consent process and ultimately a less informed patient decision to agree to a procedure. A provider may reflect societal racial biases about addiction and be more willing to prescribe narcotics to treat pain among white patients more often than black patients. And an example in nephrology: nephrologists may hold the (incorrect) opinion that the black community is somehow less likely to consider living donor transplantation and therefore be less vigilant about referring black patients with end-stage renal disease for transplant evaluation.
To explore racial disparities in access to kidney transplantation, we can design an observational study where a few dialysis centers provided providers a quarterly list of their patients. The providers were then required to state whether each patient had been referred for transplantation or not. If the patient had not been referred, a reason would need to be provided. We could then compare the reasons for deferred transplant referral across different races (and gender). If reasons differed across race/ethnicity, that could better inform further study to validate these reasons or design interventions to reverse false biases.
2) Structural issues within health care delivery are implicated in health care disparities. Please brainstorm 4 structural issues that might contribute to these disparities. Which of these are relevant to your particular area of research, and how?
1. Discordant language between provider and patient leads to misunderstanding, miscommunication, less detailed care plans, (and poor glycemic control as evidenced by the Fernandez paper). Having to interact through an interpreter (best case scenario) presents an additional time pressure during an often short clinical appointment.
2. Geographic availability of primary and specialty care. If clinics are only located in one particular neighborhood (or city), travel to receive this care may be prohibitive to certain communities
3. Insurance status heavily impacts the choice of providers and wait times to specialty care in the US. Access to premium insurance policies is often tied to employment.
4. Access to wealth can often "buy" better care. A good example is that extremely wealthy patients can game the kidney transplant system by traveling far and wide to enlist at many different transplant centers. If you are able to be multi-listed, you can increase your chances at getting a kidney in a shorter period of time.
Access to insurance is an interesting modality of disparity in dialysis outcomes research since end-stage renal disease is a Medicare-qualifying condition (eg, if you were uninsured or underinsured before starting dialysis, you’d be automatically enrolled and covered under Medicare once you started dialysis). This, however, does not apply to undocumented predominantly Latino patients in Texas. These patients are unable to enroll in Medicare, and therefore unable to be cared for in outpatient dialysis clinics. They therefore rely upon the emergency rooms for regular dialysis, which can only be provided if their potassium was sufficiently emergent (or if they were hypertensive or hypoxic enough) to need emergent dialysis. This has led to an increased rate of mortality among these patients, and is terrible example of a societal influences, structural barriers, and immigration policies can directly lead to a health disparity.
https://www.reuters.com/article/us-health-immigrants-dialysis/emergency-dialysis-for-undocumented-immigrants-tied-to-more-deaths-idUSKBN1EE2T7