For Daisy Arabella Only

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Infl uence of Patients’ Socioeconomic

Status on Clinical Management Decisions:

A Qualitative Study

ABSTRACT PURPOSE Little is known about how patients’ socioeconomic status (SES) infl u- ences 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.

METHODS The study consisted of in-depth semistructured interviews with pri- mary care physicians in Connecticut. Investigators coded interviews line by line and refi ned the coding structure and interview guide based on successive inter- views. Recurrent themes emerged through iterative analysis of codes and tagged quotations.

RESULTS We 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 man- agement decisions. As a result, physicians commonly undertook changes to their management plan in an effort to enhance patient outcomes, but they experi- enced 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.

INTRODUCTION

S ocioeconomic status (SES) infl uences health care quality and out-

comes.1-16 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.10,19,20-22 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 mea-

sured disparities in quality of care.

Susannah M. Bernheim, MD, MHS1,2

Joseph S. Ross MD, MHS3,4

Harlan M. Krumholz, MD, SM2,5,6,7

Elizabeth H. Bradley, PhD2,5

1Department of Internal Medicine, Yale

University School of Medicine; and Per-

formance Management, Yale New Haven

Health System, New Haven, Connecticut

2Robert Wood Johnson Clinical Scholars

Program, Department of Medicine, Yale

University School of Medicine, New

Haven, Connecticut

3Department of Geriatrics and Adult Devel-

opment, Mount Sinai School of Medicine,

New York, New York

4Geriatrics Research, Education and Clini-

cal Center, James J. Peter Veterans’ Admin-

istration Medical Center, Bronx, New York

5Division of Health Policy and Administra-

tion, Department of Epidemiology and

Public Health, Yale University School of

Medicine, New Haven, Connecticut

6Section of Cardiovascular Medicine,

Department of Medicine, Yale Univer-

sity School of Medicine, New Haven,

Connecticut

7Center for Outcomes Research and

Evaluation, Yale-New Haven Hospital,

New Haven, Connecticut

Confl icts of interest: none reported

CORRESPONDING AUTHOR

Susannah M. Bernheim, MD, MHS

Yale University School of Medicine

333 Cedar St

PO Box 208025

New Haven, CT 208088

[email protected]

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In the current health care environment, there

is increasing attention to individual physician per-

formance on discrete measures. Many have raised

concerns that those who provide care for vulnerable

populations, such as low-SES populations, may be at a

disadvantage in the context of public reporting of per-

formance measurement and pay-for-performance.23-26

Physicians’ perspectives on how SES affects clinical

management may offer some insight into the source of

current quality disparities, as well as inform ongoing

quality improvement efforts by highlighting specifi c

challenges to providing high-quality care for low-SES

populations. To understand better such perspectives,

we conducted in-depth semistructured interviews with

primary care physicians in Connecticut who care for

patients of low SES. We chose qualitative methods

to explore in rich detail recurrent themes regarding

physicians’ experiences caring for patients of low SES,

particularly their views about how SES infl uences both

the process of clinical care and patient outcomes.

METHODS Study Design and Participants We conducted a qualitative study, which uses methods

best suited for eliciting broad themes and patterns

when no previously described theoretical framework

exists.27,28 We undertook 18 semistructured interviews

with primary care physicians in Connecticut to elicit

their perceptions, beliefs, and experiences in caring for

patients of low SES. We chose this method of research

in the belief that physician participants were most

likely to respond candidly in the context of one-on-one

discussion with a physician interviewer.

To identify a sample of physicians who care for

patients of low SES, the population of primary care

physicians who provide care for Medicaid patients in

the state was used as a sampling frame. First, physicians

in this population were randomly identifi ed and con-

tacted for an interview. Fourteen physicians were ini-

tially contacted and 11 agreed to an interview. Second,

physicians were purposefully selected from the Med-

icaid pool to maximize variation on those character-

istics we believed might shape physicians’ perceptions

of caring for patients of low SES: race and ethnicity,

practice type (private practice, community health

center, academic practice), and practice setting (rural,

urban, suburban). Four additional physicians were con-

tacted, and all agreed to be interviewed. Last, we used

a snowball technique to identify minority physicians

and those caring for veterans who we believed were

underrepresented in our emerging sample.27 Three

physicians were identifi ed using this approach, and all

agreed to participate.

We provided written information about the proj-

ect to participants. Informed consent was completed

verbally to avoid producing written materials that

could be used to identify participants. Additionally,

any potentially identifying information given during

interviews was removed from transcripts. This project

was approved by the Institutional Review Board at

Yale University.

Data Collection All interviews were conducted by a physician inves-

tigator—a family physician (S.M.B.) or an internist

(J.S.R.). The interviews were semistructured, using an

interview guide composed of open-ended questions

and additional prompts. The interview guide was pilot

tested on 2 physicians from neighboring states before

starting the study. Interviews began with a broad ques-

tion asking how physicians thought patients’ SES infl u-

ences patient care.29 Physicians were further prompted

to give specifi c examples of changes in patient manage-

ment and encouraged to think about a range of ways

that SES infl uences care. We did not defi ne socioeco-

nomic status because we wanted to gain insight into

physicians’ own conception of SES and which factors

associated with SES they believed infl uenced patient

care management decisions. All participants completed

a brief written form describing their demographic

background, practice setting, and years of clinical

experience. Interviews were recorded and profession-

ally transcribed by an independent transcriptionist.

Data Analysis We used line-by-line open coding to develop the cod-

ing structure.27,28 Three investigators (S.M.B., J.S.R.,

E.H.B.) independently coded each transcript, tagging

sections of data with appropriate codes. After every 2

to 3 interviews, the researchers met to compare coding

and resolved differences with negotiated consensus. As

new concepts emerged, the code structure was refi ned

and the interview guide was modifi ed to refl ect emerg-

ing themes, as is common in qualitative research.27,30,31

Periodically a member of the research team (S.M.B.)

reread previously coded transcripts and recoded using

the enhanced code structure to ensure earlier data were

fully analyzed. In addition, the research team reviewed

data within codes several times to ensure consistency

in their use and full understanding of their scope and

meaning. This process is consistent with the constant

comparative method27 or editing analysis.32 From this

process, recurrent themes emerged that characterized

the experiences of the participants. Additional inter-

views were conducted until no new concepts emerged

with successive interviews, a process known as thematic

saturation.32 We selected verbatim quotations from the

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transcribed data to illustrate the recurrent themes using

Atlas-ti software (Scientifi c Software Development,

GmbH Berlin, version 5.0.67). Quotes were edited to

improve readability. A physician identifi cation number

is included after each quotation. Participating physi-

cians were contacted after the data analysis was com-

plete and given an opportunity to comment on the fi nal

themes that emerged from interviews. No substantive

changes were made during this process.

RESULTS Participants (N = 18) included 6 women, 9 physicians

from minority racial backgrounds, and 3 of Hispanic

ethnicity (Table 1). Physicians’ clinical experience

ranged from 5 to 23 years, and they practiced in a

variety of settings: community clinic, private offi ce,

academic practice, and ambulatory care clinic within a

Veterans Affairs medical center. Two physicians were

family physicians, and the others were internists.

When asked to characterize their patients of

low SES, most physicians used specifi c descriptors,

although 2 physicians said that they could not general-

ize about these patients as a group. We categorized

physicians’ descriptions into broader sets of attributes

(Table 2). These attributes included characterizations

based on not only economic and social factors, but also

on personality traits, life circumstances, and attitudes

and knowledge about medicine. Many words that phy-

sicians used to describe their patients of low SES might

be considered negative (eg, distrustful, noncompliant);

others were more positive (eg, appreciative, interested

in health). Some used a combination of both positive

and negative descriptors. In addition to these charac-

terizations, 4 recurrent themes emerged that together

portrayed the experiences of physicians caring for

patients of low SES: (1) they held confl icting views

about the effect of patient SES on clinical manage-

ment; (2) they believed that changes in clinical man-

agement due to patient SES were made in the patient’s

interest; (3) they varied in the degree to which they

thought changes in clinical management infl uenced

patient outcomes; and (4) they faced personal and

fi nancial strains caring for patients of low SES.

Confl icting Views: SES and Clinical Management Some physicians indicated that patient SES substan-

tially infl uenced clinical management and that tailor-

ing care to account for SES was central to providing

high-quality care. As one said, “I need to understand

where they are and how to fi t their mold to help them

come up with the best possible outcome [physician

4].” Most physicians’ statements, however, divulged

more confl icted views about the infl uence of patient

SES on clinical management. A common tendency was

for physicians to report their belief that the “standard

of practice should not be [infl uenced] by low socio-

economic status [physician 2].” Nevertheless, during

the course of the interviews, nearly all physicians

recounted circumstances in which the patient’s SES

Table 1. Characteristics of the Physician Sample (N = 18)

Characteristic Value

Male, No. (%) 12 (67)

Age range, years 31-54

Race, No. (%)

White 9 (50)

Asian 6 (33)

African American/black 2 (11)

Other 1 (6)

Ethnicity, Hispanic, No. (%) 3 (17)

Patient practice, years 5-23

Patient composition, No. (%)

Uninsured 0-50

Medicaid 2-70

Veterans Affairs physicians, No. (%) 2 (11)

Practice setting, No. (%)

Urban 13 (72)

Suburban 4 (22)

Rural 1 (6)

Specialty, No. (%)

Internists 16 (88)

Family physicians 2 (11)

Table 2. Physician Descriptions of Patients of Low Socioeconomic Status

Attributes Examples of Descriptors Used by Physicians

Economic Uninsured

Unemployed

On welfare Sociocultural Minority race or ethnicity

Low educational achievement

Poor social networks Personality traits Stoic

Guarded or distrustful

Appreciative Life circumstances Chaotic lives

Involvement with substance abuse

Diffi culty with transportation Attitude and knowledge

about medicine Poor health literacy

Noncompliant

Poor health behaviors

Sicker or more acute visits

Interested in health Unable to characterize

as a group Everyone is different

No general statement about them

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did affect their clinical management decisions. Even

physicians who initially asserted that all patients in

their practice received identical care later described

differences based on patient SES. For instance, 1 phy-

sician said at the beginning of an interview, “I see the

full gamut. I see the CEOs and then I see the neigh-

borhood, low-SES patients. And really, it is invisible to

me. They get the exact same approach and treatment

[physician 9].” Later in the same interview, however,

this physician described changing prescriptions and

reducing diagnostic testing because a patient had a

lower SES.

The prevailing sense that SES should not but none-

theless does infl uence clinical management decisions

was expressed by this physician:

When we see a patient, we do not really think this patient

is from the poorer strata and [so we are] going to give him a

different medication. But when it actually comes to the prac-

ticality of it, we have to, because he is not going to buy the

medication we have prescribed [physician 8].

Clinical Management Changes Made in Patient’s Interest Most of the changes physicians described as based on

a patient’s SES were made to provide care that was

more affordable, feasible, or comprehensible for a

patient. To make care more affordable to patients as a

result of income or insurance restrictions, for instance,

physicians described using less-expensive medications,

avoiding specialist referrals, trying to accomplish more

in a single visit, and postponing testing. Below a physi-

cian describes treating a patient he thought had sleep

apnea but who could not afford a sleep study or a visit

to a sleep specialist:

So I put him on oxygen. ... Right now, he is saying that

symptomatically he is feeling a little better. I still feel con-

cerned that we are treating it half-heartedly. This is not the

right treatment, but this is what we can do, and that is what

we are trying to do [physician 2].

In other cases a physician’s aim was to make care

more feasible given a patient’s lifestyle. Here a physi-

cian describes matching a diabetic patient’s care to the

patient’s occupation and work schedule:

He was a trucker … we really had to tailor the medication.

He did not have any proper time to eat, and, you know, he

did not have time to come to his appointments. We have to

tailor his appointments according to his travel schedule. It is

not optimal, but we do the best we can [physician 8].

Additionally, to make care more comprehensible,

physicians described taking more time to communicate

fewer pieces of information or incorporating family

members into discussions because of concerns about

patients’ limited literacy. In another example a physi-

cian described changing his style of speech to mir-

ror a patient’s in hopes of improving adherence and

outcomes:

Sit with me during an interview with a 26-year-old factory

worker. I don’t speak the same. I listen to him, I watch him,

I pace with him. I use his lingo, there is a lot of “dude,”

“buddy” kind of terminology. … Whatever I am trying to do

is always trying to impact the outcomes, because that is my

job [physician 11].

Clinical Management Changes and Infl uence on Patient Outcomes In some cases, physicians believed that, although they

provided different care for patients of low SES when

compared with patients of higher SES, patient out-

comes did not differ. For instance, physicians intimated

that prescribing a generic rather than a name brand

medication, changing communication styles, or elimi-

nating treatments of uncertain benefi t did not com-

promise patient outcomes generally. One physician,

in fact, described what he viewed as excessive care for

more affl uent patients:

This patient comes in with pneumonia—patient A with good

[insurance]. Here’s your Lev-pack … nasal inhaler, especially

Advair. Here’s your guaifenesin with phenylephrine with

hydroxy-blah-blah-blah. Then patient B with no insurance.

Here’s your penicillin. Take deep breaths, 3 times a day,

cough hard, humidify at night, steam inhalation will help

you as well. So SES changes things. Patient A probably will

have all the unnecessary things that I give because I play

defensive. Patient B does just as well [physician 3].

In other cases, however, physicians indicated the

clinical management decisions made to accommodate

a patient’s low SES could compromise outcomes. One

physician described patient fi nances as limiting medica-

tion choices and inevitably leading to worse outcomes

for the patient:

I’m a believer that with chronic pain you should use longer-

acting narcotics, [but] our drug of choice is just too expensive

for him. … As a result, we have been forced to use less-

expensive medications, and I’ve had great diffi culty getting

his pain under good control [physician 1].

Finally, physicians described tailoring care based on

a patient’s SES as a way to mitigate the negative impact

of SES on patient outcomes. The following physician

describes being less aggressive with diabetes treatment

as a means of enhancing outcomes for patients who

“because of the combination of their lack of insurance,

their understanding of the disease, and just what per-

sonal diffi culties they are going through at the time”

will often not show up for long periods of time. This

physician contrasted his approach with that of his col-

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leagues who were infl exible in their treatment plans,

which he believed resulted in worse outcomes for

patients of low SES:

I think my care is affected because I know that at times if

I’m too rigid, the patients won’t come back …, [so we] try to

reach an understanding with the patients, and this way per-

haps there is a compromise of care, but the other side would

be that the patients would just be lost [physician 18].

Strains of Caring for Patients of Low SES In changing their clinical management decisions to

account for a patient’s SES, physicians experienced

tension between an ideal of maintaining a consistent

standard of care for all patients and providing care that

was not the standard of care but what they believed

was appropriate given a patient’s SES. One way this

tension was conveyed was in physicians’ concern that

they may appear to be providing lower quality care to

patients of low SES, even when they believed it was in

a patient’s best interest:

I try to practice good medicine all the way through. But

sometimes when I am limited, it would seem like it is less

than good medicine. But it is still as appropriate as you can

get within the limits that you have [physician 15].

For some physicians concerns about not maintain-

ing standards of care and about worse patient out-

comes were compounded by increased attention to

performance measurement:

You are graded as a doctor by everybody in the world. Used

to be if you were a nice person and you practiced good medi-

cine that was enough, now you have to have data. What do

you do if the patient does not follow the game plan? There are

ways to try to coax the patients back in, but how much time

and energy do you have at the time [physician 11]?

In addition, physicians gave many examples of hav-

ing to work harder in an effort to maintain a standard

of care for patients of low SES. They spoke of putting

extra time into obtaining free medications or seeking

colleagues to accept specialty referrals and of adding

staff members to help patients of low SES navigate

the health care system. Furthermore, some physicians

stated that they could no longer afford to accept new

Medicaid or uninsured patients and questioned the

sustainability of the current health care system. As

one stated:

Being able to fi nd consultants, fi nd people to take care of

them, is very frustrating, and I think a lot of it comes down

to dollars and cents. It is very frustrating because it puts a

barrier right between you and the patient. And, you know,

lights have to be paid for, the staff has to be paid—if you are

not be able to do that, you are done. And so what do you

do? It is hard [physician 10].

Finally, physicians described being burdened by

fears about their level of responsibility for the infl uence

of patient SES on health care quality and outcomes:

If a patient comes in with adequate health care [coverage]

[and a blood pressure of] 190/100 mm Hg, you say, “Here,

I give you some medications to make sure that your blood

pressure goes down.” The patient with no money [and a

blood pressure of] 190/100 mm Hg, I give him some samples,

and then what? I give him a script. He does not have [the

medication because of costs]. I wonder after these 30 days,

after these pills, what is going to happen? Will I see him in

the newspaper obituary from a stroke [physician 16]?

DISCUSSION Every physician within our diverse group described

situations in which they changed their care because of

a patient’s SES. What was particularly salient in these

physicians’ responses was that, although the physicians

described many of these changes as being in a patient’s

interest, physicians were nonetheless confl icted about

the concept that the patient’s SES infl uenced clinical

management. Their discomfort was in part due to con-

cerns that patients of low SES may experience worse

outcomes, but also it was due to the tension they faced

between tailoring care to make it more feasible and the

ideal of maintaining a standard of consistent care for all

patients. These fi ndings are relevant to understanding

health care disparities and the challenges of perfor-

mance measurement.

Many of the changes that physicians described—

less aggressive diabetes management, postponement

of testing, or use of less than ideal or nonstandard

treatments as a result of fi nancial limitations—may

contribute to observed disparities in health care quality.

Although interviewed physicians described changes in

clinical management as being made in a patient’s inter-

est, it is not clear whether these changes improve or

worsen patient outcomes. Some physicians argued that

they made changes to mitigate the impact of low SES,

whereas others believed that limits on care owing to

a patient’s SES inevitably led to worse outcomes. Our

fi ndings highlight the need to explore the how tailoring

patient care affects outcomes compared with care that

is blind to SES. These results also suggest that observed

disparities may in part result from physician actions

made in what they believe to be a patient’s interest.

Medical training and health policy are evolving

toward a concept of health care that is more patient

centered. Some changes made by physicians to accom-

modate low SES, such as adapting communication to

improve understanding and adherence, align with the

priorities of patient-centered care.33-35 Importantly,

many others do not. Physicians frequently describe

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changing management in response to the fi nancial bar-

riers patients face. Tailoring care based on fi nancial

limitations, such as providing a less effective but more

affordable medication, may be appropriate, but it does

not necessarily refl ect the values or health beliefs of a

patient, as is central to most defi nitions of patient-cen-

tered care. To confl ate changes made by a physician to

accommodate a patient’s socioeconomic circumstances

with those made in response to a patient’s values and

beliefs minimizes an important distinction, which is the

constraint physicians experienced when a patient’s SES

limited feasible care plans. This constraint was a source

of considerable stress to the physicians we interviewed.

Because physicians’ reimbursement is increasingly

based on standardized quality measures, the tension

experienced by physicians to balance standards and

feasibility is more poignant. Current quality measures

do not provide guidance or adjustment for the tailoring

of care that interviewed physicians believed best met

the needs of their patients. Although fi nancial limita-

tions commonly infl uence clinical practice, physicians

are without an evidence base to guide such decisions.

Some authors have suggested provocative ways that

SES might be appropriately incorporated into treat-

ment decisions, including consideration of education

level as a risk factor for cardiovascular disease and

accounting for education when prescribing preven-

tive medications, or changing cardiac intervention

decisions based on patients’ ability to afford medica-

tions.36,37 How such changes ultimately infl uence

patient outcomes needs further investigation.

Our interviews exposed the personal and fi nancial

strains that physicians experience when caring for

populations of patients of low SES. Many of the physi-

cians no longer accept Medicaid patients, a phenom-

enon recently documented on a national level38; they

frequently spoke of burnout by those who provide care

to patients of low SES in the current health care envi-

ronment; and they fear the impact of payment linked

to performance measurement on their practice. As

national trends indicate, maintaining a physician work-

force willing to care for poor and vulnerable patient

groups is becoming more diffi cult,39 and our study sug-

gests a range of challenges that may be contributing.

There are several limitations to our study that

should be considered in its interpretation. First, we did

not use theoretical iterative sampling, in which earlier

interviews infl uence the subsequent selection of par-

ticipants,30 and we limited our sampling frame to physi-

cians from a single state caring for adult patients only.

We did include, however, a diverse sample of Connect-

icut physicians caring for patients of low SES so we

could obtain a broad range of perspectives. Second, we

interviewed only physicians; patients’ perspectives on

how SES infl uences clinical management may be dif-

ferent. Although the scope of our fi ndings is limited to

the perspective of physicians, the purpose of our work

was to explore these perspectives as an initial contribu-

tion to understanding the relationship between SES

and clinical management. Third, the interviewers were

primary care physicians with considerable experience

in caring for low-SES populations; their parallel educa-

tion and experience may have contributed to their abil-

ity to establish rapport with the physicians interviewed

but may also have infl uenced both their approach to

the interviews and their interpretation of the data. For

this reason, all interviews were additionally coded by

a third investigator, a health services researcher with

substantial qualitative research experience and exper-

tise in quality of care.

Our fi ndings identify a number of ways that physi-

cians change care based on their patients’ SES. These

changes may contribute to measured socioeconomic

disparities in health care; however, many changes are

made to enhance patient outcomes given the con-

straints associated with low SES. Explicit recognition

of the role of socioeconomic factors in clinical deci-

sion making may be an important contribution in the

development of quality standards to ensure high-qual-

ity care and a physician workforce willing to care for

vulnerable populations.

To read or post commentaries in response to this article, see it online at http://www.annfammed.org/cgi/current/full/6/1/53.

Submitted February 13, 2007; submitted, revised, August 7, 2007; accepted August 16, 2007.

Key words: Socioeconomic factors; healthcare disparities; quality of healthcare; qualitative research

This work was presented at the North American Primary Care Research Group (NAPCRG) Conference in Tucson, Arizona, October 16, 2006.

Funding support: Drs Bernheim and Ross were fellows in the Robert Wood Johnson Clinical Scholars Program at Yale University supported by the Robert Wood Johnson Foundation during time that work on this project was ongoing. Dr Bernheim was also supported by a training grant from the National Institutes on Aging (T32AG1934). Dr Ross is currently supported by funding from the Hartford Foundation and by Department of Veterans Affairs Health Services Research and Develop- ment Service project grant TRP-02-149. Dr Bradley is supported by a Catherine and Patrick Weldon Donaghue Medical Research Foundation Investigator Award.

Acknowledgments: The authors thank Kevin Fiscella, MD, for his help- ful comments on an earlier version of this manuscript.

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