Racial and ethnic disparities in the quality of primary care for children

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Original Research

Racial and ethnic disparities in the quality of primary care for children

J Fam Pract. 2002 June;51(6):1-1

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References

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Address reprint requests to Gregory D. Stevens, PhD, MHS, Department of Health Policy and Management, Johns Hopkins University School of Hygiene and Public Health, 624 N. Broadway, Rm. 661, Baltimore, MD 21205. E-mail: gstevens@jhsph.edu.

To submit a letter to the editor on this topic, click here: jfp@fammed.uc.edu.

Analysis

The independent variable was racial and ethnic background, and its analytic categories included Asian, black, Hispanic, and white. Comparisons were made between race or ethnicity and the study covariates and scores for the primary care subdomains. Frequencies of the study covariates were compared across racial and ethnic groups, and the significance of these differences was assessed with chi-squared tests of association. Generalized linear model procedures were used to assess differences in primary care quality across racial and ethnic groups after adjusting for study covariates. Bonferroni t tests were used to test significance and account for multiple comparisons.

Two total primary care scores were generated by summing the mean scores for the primary care subdomains. The first total primary care score (A) included coordination of care, a domain that was answered only by a subset of the population that reported they had visited a specialist since they first saw their regular provider. Therefore, total score A was limited to 1 subset of the population (n = 135). The second total primary care score (B) did not include coordination of care and thus included the full study sample.

Multiple linear regression analyses were conducted to predict primary care quality. Four models were constructed incrementally, with the first including only dummy variables of race and ethnicity (with white “race” as the reference group). Additional models controlled for (1) socioeconomic status covariates, (2) health system characteristics, and (3) socioeconomic status, health system characteristics, and demographics. The models were constructed separately for primary care scores A and B. Regression coefficients and respective P values are reported for race/ethnicity categories and study covariates. The coefficient of determination (R² and adjusted R²) is reported for each model to describe how much of the variance in primary care quality was explained by the study variables.

Table 2 compares the unadjusted socioeconomic status, health system characteristics, and demographic factors of our analytic sample across racial and ethnic groups. As per the sampling strategy, respondents were nearly equally divided among the 4 categories of race and ethnicity. Most respondents (74.3%) had family incomes greater than $36,000/year, although a significantly smaller proportion of black (64.2%) and Hispanic (67.7%) families had incomes above this amount compared with whites (90.2%) and Asians (84.0%; P < .001). Racial and ethnic groups also differed in maternal education and employment, with Asians reporting the highest proportion with a high school education or greater (P < .01) and blacks reporting the highest employment among mothers (P < .001).

With regard to health system factors, Asians and whites were most likely to report seeking care at a doctor’s office (58.8% and 57.0%, respectively) compared to seeking care from a health maintenance organization clinic or other setting (P < .001). Hispanics reported the largest proportion of children receiving care from a health maintenance organization clinic setting (39.4%), and Asians reported the smallest proportion (20.6%; P < .05). White respondents had the highest proportion covered by private health insurance (86.6%) and Hispanic respondents had the lowest (79.1%; P < .05). Hispanics were most likely to be uninsured (13.13%; P < .05).

Asians were most likely to report having any cost sharing such as a deductible or co-payment (83.2%; P < .01). There were no significant differences in child’s age, sex, or health status across racial and ethnic groups.

Table 3 compares adjusted primary care quality scores across racial and ethnic groups. The attribute scales were standardized by summing the responses to each question in the attribute and dividing by the number of questions (range, 1-4). In general, Asian, black, and Hispanic parents reported slightly lower quality of primary care than did whites. Minority parents reported lower scores for 6 of the 7 subdomains, although only some of the findings were significant. Asian respondents reported the lowest (or statistically equivalent to the lowest) primary care quality for 5 of the 7 domains, reflecting differences of approximately 5% to 10%. These scores were significantly lower than those reported by whites for first-contact accessibility (P < .05), first-contact utilization (P < .01), interpersonal relationship (P < .05), and comprehensiveness of services received (P < .001). Moreover, Asians reported significantly lower mean scores than did whites for both total primary care scales. Black respondents reported significantly worse first-contact utilization but slightly greater accessibility than did whites, although the difference was not significant.

Table 4 presents 4 multiple regression models for the 2 versions of total primary care quality after successive adjustment for socioeconomic status, health system characteristics, and demographics. In model 1A (not adjusted for any covariates) Asian and black races (vs whites) were significant negative predictors of primary care quality. In model 1B (ie, coordination of care domain excluded) all minority groups (vs whites) were significant negative predictors of quality (P < .01). In models 2B and 3B, after controlling for socioeconomic status and health system characteristics, respectively, 2 additional covariates positively predicted total primary care quality. These were family income greater than $36,000 (P < .01) and having a pediatrician as opposed to any other type of family practitioner or generalist primary care provider (P < .001). Despite the addition of these covariates to models 2 and 3, minority racial and ethnic groups remained significant negative predictors for both versions of primary care quality (P < .05). Asian race remained a particularly significant predictor of quality (P < .001).