Journal of General Internal Medicine

, Volume 22, Issue 7, pp 976–981

Are Physician Estimates of Asthma Severity Less Accurate in Black than in White Patients?

  • Sande O. Okelo
  • Albert W. Wu
  • Barry Merriman
  • Jerry A. Krishnan
  • Gregory B. Diette
Original Article

Abstract

Background

Racial differences in asthma care are not fully explained by socioeconomic status, care access, and insurance status. Appropriate care requires accurate physician estimates of severity. It is unknown if accuracy of physician estimates differs between black and white patients, and how this relates to asthma care disparities.

Objective

We hypothesized that: 1) physician underestimation of asthma severity is more frequent among black patients; 2) among black patients, physician underestimation of severity is associated with poorer quality asthma care.

Design, Setting and Patients

We conducted a cross-sectional survey among adult patients with asthma cared for in 15 managed care organizations in the United States. We collected physicians’ estimates of their patients’ asthma severity. Physicians’ estimates of patients’ asthma as being less severe than patient-reported symptoms were classified as underestimates of severity.

Measurements

Frequency of underestimation, asthma care, and communication.

Results

Three thousand four hundred and ninety-four patients participated (13% were black). Blacks were significantly more likely than white patients to have their asthma severity underestimated (OR = 1.39, 95% CI 1.08–1.79). Among black patients, underestimation was associated with less use of daily inhaled corticosteroids (13% vs 20%, p < .05), less physician instruction on management of asthma flare-ups (33% vs 41%, p < .0001), and lower ratings of asthma care (p = .01) and physician communication (p = .04).

Conclusions

Biased estimates of asthma severity may contribute to racially disparate asthma care. Interventions to improve physicians’ assessments of asthma severity and patient–physician communication may minimize racial disparities in asthma care.

KEY WORDS

asthma racial disparities patient–physician communication 

References

  1. 1.
    CDC Report: asthma—United States, 1982–1992. Morb Mort Wkly Rep 1995;43:952–5.Google Scholar
  2. 2.
    Strunk RC, Ford JG, Taggart V. Reducing disparities in asthma care: priorities for research—National Heart, Lung, and Blood Institute workshop report. J Allergy Clin Immunol. 2002;109(2):229–37.PubMedGoogle Scholar
  3. 3.
    Krishnan JA, Diette GB, Skinner EA, Clark BD, Steinwachs D, Wu AW. Race and sex differences in consistency of care with national asthma guidelines in managed care organizations. Arch Intern Med. 2001;161(13):1660–8.PubMedGoogle Scholar
  4. 4.
    Wolfenden LL, Diette GB, Krishnan JA, Skinner EA, Steinwachs DM, Wu AW. Lower physician estimate of underlying asthma severity leads to undertreatment. Arch Intern Med. 2003;163(2):231–6.PubMedGoogle Scholar
  5. 5.
    Collins KS, Tenney K, Hughes DL. Quality of health care for African Americans: findings from the Commonwealth Fund 2001 health care quality survey. The Commonwealth Fund. 2002;524:1–2.Google Scholar
  6. 6.
    Steinwachs DM, Wu AW, Skinner EA, et al. Outcomes management system: asthma final report to managed health care association, outcomes management system project. Managed Health Care Association. Baltimore, Maryland, Johns Hopkins University, 1996Google Scholar
  7. 7.
    Diette GB, Wu AW, Skinner EA, et al. Treatment patterns among adult patients with asthma: factors associated with overuse of inhaled beta-agonists and underuse of inhaled corticosteroids. Arch Intern Med. 1999;159(22):2697–704.PubMedGoogle Scholar
  8. 8.
    Guidelines for the diagnosis and management of asthma— National Heart, Lung, and Blood Institute National Asthma Education, Program Expert Panel Report. J Allergy Clin Immunol. 1991;88(3 pt 2):425–534.Google Scholar
  9. 9.
    US Department of Health and Human Services. International Consensus Report on Diagnosis and Management of Asthma. PHS/NIH Publication No 91-3091, 1992.Google Scholar
  10. 10.
    National Asthma Education and Prevention Program Expert Panel Report: guidelines for the diagnosis and management of asthma—update on selected topics, 2002. J Allergy Clin Immunol 2002;110, Part 2(5):S142-S219.Google Scholar
  11. 11.
    Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med. 2005;353(7):692–700.PubMedGoogle Scholar
  12. 12.
    Jha AK, Fisher ES, Li Z, Orav EJ, Epstein AM. Racial trends in the use of major procedures among the elderly. N Engl J Med. 2005;353(7):683–91.PubMedGoogle Scholar
  13. 13.
    Vaccarino V, Rathore SS, Wenger NK, et al. Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002. N Engl J Med. 2005;353(7):671–82.PubMedGoogle Scholar
  14. 14.
    Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C.: National Academies Press; 2002.Google Scholar
  15. 15.
    Collins KS, Hughes DL, Doty MM, Ives BL, Edwards JN, Tenney K. Diverse communities, common concerns: assessing health care quality for minority Americans: findings from the Commonwealth Fund 2001 health care quality survey. The Commonwealth Fund Publication 523 2 A.D.Google Scholar
  16. 16.
    Roter DL, Stewart M, Putnam SM, Lipkin M, Stiles W, Inui TS. Communication patterns of primary care physicians. JAMA. 1997;277(4):350–6.PubMedGoogle Scholar
  17. 17.
    Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient–physician relationship. JAMA. 1999;282(6):583–9.PubMedGoogle Scholar
  18. 18.
    Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907–15.PubMedGoogle Scholar
  19. 19.
    Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient–physician communication during medical visits. Am J Public Health. 2004;94(12):2084–90.PubMedGoogle Scholar
  20. 20.
    Thamer M, Hwang W, Fink NE, et al. US nephrologists’ attitudes towards renal transplantation: results from a national survey. Transplantation. 2001;71(2):281–8.PubMedGoogle Scholar
  21. 21.
    van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med. 2000;50(6):813–28.PubMedGoogle Scholar
  22. 22.
    Clark NM, Gong M, Schork A, et al. Impact of education for physicians on patient outcomes. Pediatrics. 1998;101(5):831–6.PubMedGoogle Scholar
  23. 23.
    Bergmann MM, Byers T, Freedman DS, Mokdad A. Validity of self-reported diagnoses leading to hospitalization: a comparison of self-reports with hospital records in a prospective study of American adults. Am J Epidemiol. 1998;147(10):969–77.PubMedGoogle Scholar
  24. 24.
    Wagenknecht LE, Burke GL, Perkins LL, Haley NJ, Friedman GD. Misclassification of smoking status in the cardia study—a comparison of self-report with serum cotinine levels. Am J Public Health. 1992;82(1):33–6.PubMedCrossRefGoogle Scholar
  25. 25.
    Wills TA, Cleary SD. The validity of self-reports of smoking: analyses by race/ethnicity in a school sample of urban adolescents. Am J Public Health. 1997;87(1):56–61.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Sande O. Okelo
    • 1
  • Albert W. Wu
    • 2
    • 3
    • 4
  • Barry Merriman
    • 4
  • Jerry A. Krishnan
    • 2
    • 4
  • Gregory B. Diette
    • 2
    • 4
  1. 1.Department of PediatricsJohns Hopkins UniversityBaltimoreUSA
  2. 2.Department of MedicineJohns Hopkins UniversityBaltimoreUSA
  3. 3.Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  4. 4.Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA

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