Differences in the Quality of the Patient-Physician Relationship Among Terminally Ill African American and White Patients: Impact on Advance Care Planning and Goals of Care

1
Differences in the Quality of the
Patient-Physician Relationship Among Terminally
Ill African American and White Patients Impact
on Advance Care Planning and Goals of Care

• Alexander K. Smith, MD, MS, Roger B. Davis, ScD,
  Eric L. Krakauer, MD, PhD

Division of General Medicine and Primary Care,
Beth Israel Deaconess Medical Center, Boston,
MA Division of Palliative Care, Massachusetts
General Hospital, Boston, MA
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Previous Disparities Research

• African Americans, compared to Whites
• greater preference for life-sustaining treatment
• less likely to have living will or HCP
• report lower quality interactions with their
  physicians
• Impact of relationship quality on care may be
  magnified in terminal illness

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Aims

• To compare the quality of the patient-physician
  relationship between terminally ill
  African-American and White patients
• To examine the extent to which quality of the
  relationship contributes to differences between
  African Americans and Whites in advance care
  planning and goals of care

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Study sample

• In-person surveys Commonwealth Cummings study
• 803 African American and White patients
• Physician estimated survival of 6 months
• Referred from randomly selected physicians 5
  metropolitan areas, 1 rural county
• Response rate 87
• 1996-1997

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Patient-Physician Relationship Measures

• 6 patient reported patient-physician relationship
  quality measures (4 point scale, dichotomized at
  strongly agree vs. other responses)
• Trust in physician
• Feels respected by physician
• Physician skilled in breaking bad news
• Physician skilled at listening
• Physician shares decision making
• Physician helps navigate the medical system

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Advance Care Planning and Goals of Care

• Presence of an advance care plan (any of
  following)
• Living will
• Health care proxy
• Talked with family about plans for EOL care
• Talked with physician about plans for EOL care
• Goal of prolong life however possible

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Statistical Analysis

• Predictor African American vs. White
• Estimated relative risks using Poisson regression
  with robust error variances
• Sequential models
• Unadjusted
• Adjusted for age, gender, education, primary
  disease, and recruitment site
• Adjusted for age, gender, education, primary
  disease, recruitment site, and all measures of
  the quality of the patient-physician relationship

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Sample Characteristics
African American (n115) White (n688)
Age lt 65 52 42
Female Sex, 66 51
Income lt15,000 63 31
Less than high school graduate 55 26
Primary Disease
Cancer 48 54
Heart Disease 14 18
COPD 5 13
Renal Disease 13 1
Other 20 15
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Patient Reported Quality of the Patient-Physician
Relationship, Terminally Ill African Americans
Compared to Whites





plt.05 trust in physician, p.08
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Goals and Advance Care Planning,, Terminally Ill
African Americans Compared to Whites


plt.05
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Goals and Advance Care Planning,, Terminally Ill
African Americans Compared to Whites



plt.05
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Relative Risk of Having an Advance Care Plan
African Americans Compared to Whites
Unadjusted
Adjusted for age, sex, education, primary
disease, and recruitment site
Adjusted for age, sex, education, primary
disease, recruitment site, and all measures of
the quality of the patient-physician relationship
0.2
0.6
1.0
Relative Risk (Reference group is Whites, RR1.0)
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Relative Risk of a Goal of Prolong Life However
Possible African Americans Compared to Whites
Unadjusted
Adjusted for age, sex, education, primary
disease, and recruitment site
Adjusted for age, sex, education, primary
disease, recruitment site, and all measures of
the quality of the patient-physician relationship
1.0
2.0
3.0
4.0
0
Relative Risk (Reference group is Whites, RR1.0)
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Summary

• Among this terminally ill sample of patients
• compared to Whites, African Americans gave lower
  ratings of the quality of the patient-physician
  relationship
• While 80 of Whites had an advance care plan,
  less than half of the African Americans had an
  advanced care plan.
• Patient reported quality of the patient-physician
  relationship did not explain differences in
  advance care planning and goals of care between
  African-Americans and Whites.

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Limitations

• Data from 1996-1997
• Single measure of race/ethnicity
• Physicians may have referred patients with strong
  relationships
• Cross sectional study

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Conclusions/Implications

• Physicians referred patients prognosis 6
  months, yet only 25 of physicians talked with
  patients about plans for EOL care
• In the context of low overall discussion rate,
  quality of the patient-physician relationship had
  no impact on differences in advance care planning
  and goals of care

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Conclusions/Implications

• Focus improving physician relationships with
  African American patients
• Future research should search for other potential
  mediating factors
• Values
• Cultural beliefs
• Health literacy
• Attitudes toward the health care system
• Treatment by the health care system

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Thank you