Influence of Patients' Socioeconomic Status on Clinical Management Decisions: A Qualitative Study

Abstract

PURPOSE Little is known about how patients' socioeconomic status (SES) infl uences physicians' clinical management decisions, although this information may have important implications for understanding inequities in health care quality. We investigated physician perspectives on how patients' SES infl uences care. METHODSThe study consisted of in-depth semistructured interviews with primary care physicians in Connecticut. Investigators coded interviews line by line and refi ned the coding structure and interview guide based on successive interviews. Recurrent themes emerged through iterative analysis of codes and tagged quotations. RESULTSWe interviewed 18 physicians from varied practice settings, 6 female, 9 from minority racial backgrounds, and 3 of Hispanic ethnicity. Four themes emerged from our interviews: (1) physicians held confl icting views about the effect of patient SES on clinical management, (2) physicians believed that changes in clinical management based on the patient's SES were made in the patient's interest, (3) physicians varied in the degree to which they thought changes in clinical management infl uenced patient outcomes, and (4) physicians faced personal and fi nancial strains when caring for patients of low SES.CONCLUSIONS Physicians indicated that patient SES did affect their clinical management decisions. As a result, physicians commonly undertook changes to their management plan in an effort to enhance patient outcomes, but they experienced numerous strains when trying to balance what they believed was feasible for the patient with what they perceived as established standards of care. Ann Fam Med 2008;6:53-59. DOI: 10.1370/afm.749. INTRODUCTIONS ocioeconomic status (SES) infl uences health care quality and outcomes. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Patients of low SES receive fewer preventive services, 1,6,8,12 worse diabetes care, 1,2,15 and fewer indicated cardiac interventions. 7,16 Moreover, SES disparities exist even among fully insured patients. 4,5,8,13 Eliminating disparities in health and health care is a top priority of the National Institutes of Health and one of the overarching goals of Healthy People 2010. 17,18 SES is a complex characteristic, generally understood to encompass not only income and education level, the measures most commonly used, but also a wide range of associated factors that may affect the quality of health care patients receive, including insurance status, access to care, patients' health beliefs, and many facets of the doctor-patient relationship, such as trust and communication. 10,19,[20][21][22] Little is known, however, about how low SES ultimately infl uences physicians' decision making regarding clinical management of patients and thus how SES may contribute to measured disparities in quality of care.Susannah M. Bernheim, MD, MHS 1,2 Joseph S. Ross MD, MHS 3,4 Harlan M. Krumholz, MD, SM 2,5,6,7 Elizabeth H. Bradley, PhD S O CIOECONO MIC S TAT US A ND C L INIC A L DECISIONSIn the current health care environment...

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