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.

In model 4A, which controlled for all covariates, older child age and, nonintuitively, being uninsured were significant positive predictors of quality (likely due to the small number of uninsured respondents). In model 4B, health status was a significant predictor of quality (P < .05). With the addition of the full complement of covariates, Hispanic and black race and ethnicity became nonsignificant in both models despite small changes in the magnitude of the coefficients and P values (.07 and .06, respectively). The loss of significance in this model is likely attributable to the number of variables that was controlled for given the moderate sample size rather than to any confounding effects of specific covariates. In model 4A, Asian race remained a significant negative predictor of quality (P < .05). In model 4B, Asian race remained a strong negative predictor of quality and having a pediatrician remained a strong positive predictor (P < .001 for both). After adjustment for the natural rise in R² associated with the inclusion of additional covariates, the final models for both total scales (A and B) explained only about 8% and 11%, respectively, of the variation in primary care quality.

Discussion

This community-based study advances the literature by demonstrating that Asian, black, and Hispanic children experience poorer quality of primary care than whites, even after controlling for many differences in socioeconomic status, health system factors, and demographics. This suggests that racial and ethnic differences in quality of care are not simple reflections of ability to pay, health disparities, or other sociodemographics.

The findings in this study that parents of minority children, in particular Asian Americans, report lower quality of primary care is consistent with previous research among adults but has not been demonstrated previously for children.^20-24 This finding is particularly important because of the growing numbers of Asian Americans in the United States and because Asian children, despite their family’s higher education, are more likely than whites and some other ethnic groups to be in fair or poor health, underimmunized, and at risk for contracting preventable illnesses such as hepatitis B.^31-33 These differences in health and health risk may be remedied in part by the receipt of high-quality primary care.³⁴

Of the primary care measures, the greatest difference between Asians and whites was in comprehensiveness of services received. This domain covered the range of services that patients could receive from their regular provider and included items such as preventive counseling and discussions about growth and development. Although language was unlikely to be a determinant of quality in this study (because we excluded those unable to complete the survey in English or Spanish), it does not discount the potential of undetected or unstudied language difficulties to enhance disparities in health care. For example, even though Asian families in our study were able to communicate sufficiently in English, they might have rated the patient-provider relationship lower because of trouble finding a provider who spoke their language. Regardless, the finding suggests the importance of making services more widely available to minority groups, including improvements in communication about existing primary care services.

An interesting secondary finding was that parents who reported a pediatrician as the child’s regular source of care reported higher quality primary care than did parents reporting other generalist providers. In particular, pediatricians appeared to perform better than other providers on 3 of the attributes: utilization of services (P < .02), patient-provider relationship (P < .0001), and services provided (P < .0001; data not shown). The differences may be attributable in part to the greater frequency of visits to pediatricians for well-child care; thus, greater opportunities may exist for delivery of preventive services and the development of the patient-provider relationship. Future research should explore the experience of minority patients receiving care from various provider specialties.

Despite significant findings, the most comprehensive regression models explained only a small proportion of the variation in primary care quality (about 11%). Other factors that may play a role in determining primary care quality, but were not included in this analysis, include health insurance plan restrictions (discussed in an upcoming paper), practice arrangements, racial concordance between the patient and provider, family mobility, and perhaps provider-specific factors such as training or years in practice.

This study has several limitations. First, the cross-sectional design and analysis allowed the demonstration of association and not of causality. Second, this study examined only 4 broad classifications of race and ethnicity that do not capture within-group variations in ethnicity or culture that could be associated with differences in quality of care received. Standard measurements of race and ethnicity also do not fully capture biologic, cultural, socioeconomic, and political aspects of multiculturalism that may interact and produce more complex findings than those reported.³⁵