Yuhua Bao, Ph.D. † , Sarah Fox, Ed.D. † , Jose Escarce, M.D., Ph.D. ‡

1. Socioeconomic and Racial/Ethnic Differences in the Discussion of Cancer Screening:“Between-” vs. “Within-” Physician Differences Yuhua Bao, Ph.D.†, Sarah Fox, Ed.D.†, Jose Escarce, M.D., Ph.D. ‡ † Center for Community Partnerships in Health Promotion, UCLA General Internal Medicine/Health Services Research ‡ UCLA GIM/HSR Funded by the NIH EXPORT Center at UCLA/DREW (YB), NCI (SAF) and AHRQ (JE)

2. Socioeconomic and Racial/Ethnic Disparities in Cancer and Cancer Screening • Recent years saw steady decline in cancer death rates and improvement in cancer survival • However, disparities by patient socioeconomic status (SES) are substantial in • Adherence with cancer screening guidelines • Stage of diagnoses • Mortality and survival • Differences by patient race/ethnicity are less consistent, but • Mortality from all cancers is highest among Blacks

3. The Role of Physician-Patient Communication • Differential adherence to cancer screening is partly due to differences in access to care. However, • Disparities in cancer screening utilization exist even among people with a usual source of care • People of low-SES more likely to cite • “I didn’t know I need it” and • “Dr did not recommend it” as barriers to cancer screening (Finney et al. 2003) • Disparities in cancer screening communication may have played a role

4. The “Within-” vs. “Between-” Physician Differences • Once patients get access to health care, treatment disparities arise because • Patients of different SES or race/ethnicity are treated differently by the same physicians (“within-physician” differences), AND / OR • They are treated by a different group of physicians (“between-physician” differences)

5. “Within-physician” Differences

6. Possible Mechanisms for“Within- Physician” Differences • Patient-level factors • Low-SES and/or racial/ethnic minority patients are less aware of the need for cancer screening (Finney et al. 2003) • They are less assertive / proactive in clinical encounters • Physician-level factors • Physicians may perceive them to be less interested (van Ryn and Burke 2000) • Physicians may have greater difficulties in assessing their needs and preferences (Balsa and McGuire 2001; 2003) • Patient-physician interaction • Patient preferences and physician attitudes and perceptions are reinforced (IOM 2002)

7. “Between-physician” Differences Dr. A Dr. B

8. Possible Mechanisms for “Between- Physician” Differences • Physicians serving disproportionately more minority or low-SES patients • May be less well trained • Are less likely to be board-certified (Bach et al. 2004) • Are more likely to be foreign medical school graduates (Bellochs and Carter 1990) • May be less knowledgeable about national preventive care guidelines (Ashford et al. 2000) • They may also have less resources in the community such as • Specialty groups with cancer screening capabilities • Institutional support for preventive care • Some of the “within-physician” differences may be reinforced to become practice patterns

9. Research Question How much of the differences in cancer screening discussion were due to “within-” vs. “between-“ physician differences?

10. Data: the Communication in Medical Care (CMC) Studies • A research series that promotes physician-patient communication on important preventive care topics • Aimed at developing and testing a physician-patient communication model to change patient health behaviors • The second and third studies in the series (CMC2&3) are both randomized controlled community trials that • Teach the model in a Continuing Medical Education (CME) program • Focused on cancer screening behaviors

11. Data: Patient and Physician Samples • Physicians: office-based, primary care, practicing at least 50% of the time • CMC2: Los Angeles County • CMC3: all southern California except LA County • Patients: having seen and expect to see study physician regularly, speaking either English or Spanish • CMC2: 50-80 • CMC3: 65-79 • Data pooled from CMC2&3 baseline • Physicians: N=191 • Patients: N=5978 • On average, patients had seen their physicians for 5 years • Number of patients per physician: mean=31, median=30, range: [2, 83]

12. Outcomes of Interest: Cancer Screening Discussion

13. Statistical Strategies • Probit model of cancer screening discussion • Two specifications for each cancer screening discussion outcome • Model 1: Patient characteristics only • to assess the “overall” differences • Model 2: Model 1 + Physician Fixed Effects • Differences that remain reflect “within-physician” differences • “Between-physician” differences=“Overall” – “Within” • We report • probabilities of discussion for each racial/ethnic or SES group compared to a reference group • Bootstrapped standard errors (and p-values) to provide statistical inferences

14. By Education: Discussion of FOBT Compared to college graduates * p <0.05; ** p<0.01

15. By Education: Discussion of Mammogram Compared to college graduates * p <0.05; ** p<0.01

16. By Education: Discussion of PSA Compared to college graduates * p <0.05; ** p<0.01

17. By Income: Discussion of FOBT Compared to annual income of $75+ * p <0.05; ** p<0.01

18. By Income: Discussion of Mammogram Compared to annual income of $75+ * p <0.05; ** p<0.01

19. By Income: Discussion of PSA Compared to annual income of $75+ * p <0.05; ** p<0.01

20. Summary of findings • Disparities by education • Strong education gradient in the discussion of all three types of cancer screening • Most of the education differences arose within physicians • Disparities by income • Less consistent across different screening methods, but • Seemed to have arisen because of “between- physician” differences • Differences by race/ethnicity • Asian/white differences in the discussion of FOBT and PSA were mostly “within-physician” differences • Same physicians were much more likely to have discussed mammogram with black than white patients

21. Study Limitations • Patient self-report of clinical encounter experience may not be consistent with what really happened • If low-SES patients tend to under-report physicians’ discussion • Both within- and between- differences by SES are biased up • But hard to say how that might change the relative magnitude of the two types of differences • It depends on the distribution of low (vs. high) SES patients across physicians • On the other hand, it is arguable that what patients recall is what matters • Small sample sizes for some racial/ethnic groups • Findings regarding racial/ethnic differences should be interpreted with caution

22. Implications • Patient education plays an important role in determining what happens in a clinical encounter • Tailor patient informational materials to the needs of low-education patients • Raise the awareness of physicians about the challenges faced by low-education patients • Physicians are not evenly distributed across communities of different levels of income • Targeting physicians practicing in low-income communities may be especially promising • Geographic accessibility of providers is important to low-income patients