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?
Physicians can unknowingly contribute to healthcare disparities as a result of both conscious and subconscious decisions about what treatments to recommend to a patient and how those treatments are presented. Ryn and Fu discuss how social cognition influences provider behavior. One area applicable to nephrology, which was briefly alluded to in our reading, is differences in referral rates for kidney transplantation candidacy evaluation for Caucasian vs. African American patients, despite similar rates of self-reported interest between the two populations. One way to understand why this occurs could be to evaluate reasons providers report for not referring some of their patients (e.g., perceived lack of social support or lack of patient interest? Or perceived lack of health literacy and inability to manage their own care post-operatively?).
Another area of nephrology where I have witnessed how social cognition affects care is when patients’ “suitability” for peritoneal dialysis (over hemodialysis) is discussed. Studies suggest that PD better protects residual renal function, which can have an important impact on patients’ quality of life, and surveys show that most nephrologists would prefer PD over HD if forced to choose a treatment modality for themselves. PD generally preserves patient independence better than in-center HD but also requires much more active patient participation in their own care. As a result, sometimes nephrologists are less willing to recommend PD as the preferred treatment modality because they are not sure the candidate is able to learn how to do PD or have reservations that the patient’s social situation is stable enough to allow for PD. While these are legitimate concerns because of the high risk of peritonitis when patients do not use proper sterile technique or do not have access to appropriate environments in which to perform their PD exchanges, PD is ironically the most common ESRD treatment modality worldwide, particularly in resource-poor settings outside of the U.S. Studies comparing reasons for not choosing PD from both the patient’s and provider’s perspectives would be useful to understand this conundrum. I also wonder whether reimbursement policies affect physicians’ decisions, since peritonitis rates at dialysis facilities are now tracked and tied to Medicare payments. It may be informative to compare PD referral rates (i.e., for PD education) and PD initiation rates before and after the Quality Incentive Program, which tied reimbursement to metrics such as peritonitis rates, was implemented.
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?
Some structural issues within healthcare delivery that may contribute to healthcare disparities include: geographic barriers reducing access to care (including transportation obstacles), lack of support services to help patients without adequate health insurance, lack of access to interpreters (coupled with language barriers), and lack of culture-inclusive educational materials (e.g., written information meant to provide dietary counseling that only includes foods in the Western diet). All of these issues are potentially relevant to clinical trials involving patients with dialysis-requiring acute kidney injury: even though recruitment is typically done in the inpatient setting (many of these patients are critically ill), geographic barriers and an inability to address lack of health insurance can severely hamper follow-up efforts (investigators may forgo enrolling some patients because of concerns about loss to follow-up). Geographic barriers also include lack of nearby centers where lab draws can be done -- for patients who may be recovering kidney function and need frequent lab checks to ensure they are safe as they are weaned off dialysis, this problem may result in these patients being inadvertently kept on dialysis longer than necessary (or indefinitely), which distorts outcome assessment. Medical centers without enough access to interpreters may not be able to enroll a diverse patient population. These language barriers can also affect participant recruitment not only because it is financially costly to translate study documents but also because assuring informed consent in patients with limited English proficiency is usually much more time-consuming as well. Lack of culturally sensitive educational materials can also exacerbate disparities in health literacy, which can subsequently affect how likely certain groups of patients are approached for trial enrollment.