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?
- Significantly. Van Ryn lays out multiple layers through which race/ethnicity, culture and identity converge at the level of the provider and impact health care delivery and behavior of the help seeker. My specific area of research is in disparities around housing status in HIV care. This is an area where there are substantial, overlapping drivers of disparities in providing clinical care - race/ethnicity, socioeconomic status, mental health/substance use – that influence providers perceptions of patients. In HIV care, first is providers’ assessment of adherence. First is that providers’ assessment of adherence is often poorly predictive of actual adherence (Roberts et al AIDS 2006), and can depend on socioeconomic factors such as housing status and drug use (Kidder et al AJPH 2007; Loughlin et al AIDS Care 2004). Decreased routine health maintenance has also been documented by housing status (Clemenzi-Allen et al IDWeek 2018), and subspecialty referrals may also be impacted by similar mechanisms. Research first needs to focus on the prevalence of housing status in our clinic population by making routine surveillance of housing status within our patient populations. Further, we need to make routine monitoring of disparities in clinical outcomes: retention in care, uptake of routine care delivery, and clinical outcomes such as virologic suppression, part of quality measurements for clinic performance (Fiscella et al Ann Pub Heal Rev 2016). Next, education about the impacts of provider bias should be administered and programs should be instituted to diminish its impact on providers Devine et al. Journal of Experimental Social Psychology 2012). Moreover, systems to perform routine care (STD testing, HbA1c testing, Lipid testing, FOBT testing) should be performed by automated systems rather than overburdened providers. This will limit the impact of provider judgement on administering routine care.
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?
- In terms of health care delivery systems, access to routine care may be substantially limited in people without a permanent address. From anecdotal experience, patients will often have a lapse in health care coverage, and have onerous barriers to entering care if they have no permanent addresss. Furthermore, normal maintaining consistent clinic schedules may be difficult for patients experiencing homelessness due to competing needs and limited resources (no bus fair, access to shelter beds, etc). For this reason, clinic can adapt, making drop-in primary care appointments, or having separate appointments for routine health care maintenance (vaccines, STD screening, lipid screening, etc). This is a patient-centered approach that can enhance contact with the health care system. Furthermore, mobile outreach teams can provide health care in the field to patients that cannot present to clinic-based care. This will allow providers to deliver service where patients “are at”, working around important barriers to care such as transportation, stigma, etc, that would be encountered in a 4-wall clinic.