Ferguson JA, Weinberger M, Westmoreland GR, Mamlin LA, Segar DS, Greene JY, Martin DK, Tierney WM.
Racial disparity in cardiac decision making: result from patient focus groups.
Arch Int Med 1998;158(13):1450-3.

In an attempt to increase understanding of the reasons for racial disparities in cardiac care, this study explored the similarities and differences in the perceptions, attitudes and elements of decision-making among 58 white and 43 black patients who had recently received treatment (in-hospital or in the emergency department) for suspected or confirmed ischemic heart disease at one of two Indianapolis university-affiliated hospitals (one Veterans Affairs hospital and one community hospital, both staffed by the Indiana University School of Medicine). The stated purposes of the investigation were (1) to identify factors that contributed to patient decision-making in ischemic heart disease and (2) to determine whether racial groups differed with regard to these decision-making factors. The authors cite several earlier studies noting higher refusal rates by African-Americans for recommended bypass surgery and other cardiac procedures as a basis for this further investigation. To accomplish these aims, recruited patients were grouped into 15 focus groups, each homogenous with regard to race, age, sex and encounter site (hospitalization or emergency room). Through the use of trained facilitators using a conversation guide, these groups were encouraged to take part in open-ended discussions regarding their general perceptions of the health care system, the information they received from their physicians, how they contemplated treatment options, with whom they discussed these options, and any other factors that may have influenced their decision-making. Transcripts of these sessions were then reviewed by three general internists, a cardiologist, a medical sociologist and a biostatistician, each blinded to focus group composition. Lists of decision-making factors mentioned by patients were grouped into three categories – health care system factors, personal factors, and physician factors – and aggregated by race regardless of other group characteristics such as sex, hospital and encounter site.

Both white and black patients felt that the health care system was complex and confusing, that they had to see too many physicians, and that the medical information presented to them was difficult to understand. Similarly, white and black patients mentioned the same personal factors. These concerns included the importance of the counsel of family members, the need for second opinions, the value of information from patients who had undergone the same procedures, and the seriousness of illness as dictating decision-making and agreement with a doctor’s recommendation. Finally, both groups expressed preferences for physicians who are caring, unhurried, and listen to their patients. In each of these categories, however, there were comments uniquely added or emphasized by African-Americans. These included perceptions of mistrust in the system, undesirable physician behavior, discrimination on the basis of insurance or race. African-Americans also emphasized the importance of religious faith and trust in God in the final health care decision, and they particularly valued physician honesty, personal attention, and patient-physician camaraderie.

The authors conclude that at least two fundamental principles of patient care must be improved if racial disparities are to be reduced. Medical education and health care training programs must focus on the importance of provider communication, particularly with minority patients, and “health care professionals must be aware of and strive to eliminate the negative influence of verbal and nonverbal expression of biases that they project when interacting with patients.”

The study did not review patient records and thus offers no information as to whether the two racial groups differed in actual receipt of cardiac procedures and in acceptance or rejection of physician recommendations. Thus, there is no way to determine whether the racially different attitudes and perceptions were in fact translated into differences in cardiac care or in actual patient decision-making. Furthermore, as the authors indicate, it is not possible to tell whether the negative attitudes expressed by African-Americans were a result of real differences in the way they were treated or reflected a hesitancy to undergo additional medical therapies.

On one hand, this qualitative study would seem to support the frequently cited explanation that African-Americans’ (and other minorities’) mistrust of the health care system, perceptions of discrimination, and fear of experimentation (the so-called Tuskegee Syndrome)—in sum, “patient choice”—contribute to racial disparities in cardiac treatment. On the other hand, these findings conflict with a number of recent prospective studies that find that patient preference is a minor factor in these disparities, which are overwhelmingly determined by physicians’ decisions. It is of interest that the authors propose physician-centered remedies, including not only improved communication but the elimination of even inadvertent expressions of physician bias.