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Perspectives: Saif S. Rathore and Harlan M. Krumholz Differences, Disparities, and Biases: Clarifying Racial Variations in Health Care Use Ann Intern Med 2004; 141: 635-638 [Abstract] [Full text] [PDF]

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Conceptual Framework for Patients' Preferences and Disparity in Health Care Use

Adrian D Kenny, Jeffrey N. Katz MD, MSc and Elena Losina PhD   (15 December 2004)

Conceptual Framework for Patients' Preferences and Disparity in Health Care Use 15 December 2004
Adrian D Kenny, BS Harvard Medical School and Brigham and Women's Hospital, Jeffrey N. Katz MD, MSc and Elena Losina PhD Send rapid response to journal: Re: Conceptual Framework for Patients' Preferences and Disparity in Health Care Use adrian_kenny{at}student.hms.harvard.edu Adrian D Kenny, et al.	Letter to the Editor: Rathore and Krumholz (October 19 issue)(1) summarize essential concepts regarding research on ethnic, racial and other disparities in health care use. Specifically they define “difference,” “disparity” and “bias,” as components of a three-tiered framework for disparities research. Based on these concepts the authors propose five formal criteria for determining whether a difference in treatment or health care use should be identified as a disparity. The authors suggest that patients’ preferences should be thoroughly examined and accounted for in the decision to categorize a variation in health care use as a ‘disparity’. While we agree with the authors that patients’ preferences may contribute to variation in health care use, we are concerned that this approach may implicitly characterize preferences as fixed personal attributes that should be accepted at face value. On the contrary, as we have noted elsewhere, we believe that patient preferences are dynamic and reflect patient-provider communication, health literacy and knowledge, trust and compatibility with physicians, subtle or overt discrimination, level of health insurance, resources for out of pocket costs, geographic proximity to care and adequate transportation, as well as cultural tradition that may favor less invasive or alternative treatments (2). When, for example, an African American patient says he or she does not wish to have a particular surgery, we must wonder whether this preference reflects a well informed balancing of risks and benefits or, alternatively, overestimation of risks, concern about costs, and deeply held fears of receiving care in hospitals that for generations denied his or her forebearers entry. Patient preferences may obscure disparities unless we consider the range of social, economic and cultural factors that give rise to preferences. On a practical note, we suggest a few simple questions that researchers and providers can use to reflect and elicit more authentic and well informed preferences: 1. Is the patient well informed about the treatment options? 2. Have the available options for treatment been communicated in a manner that the patient understands? 3. Are the patient’s estimates of risk and benefit realistic? 4. How did the patient develop his or her expectations of outcome? Does the patient know anyone who has had the treatment? What was the outcome? 5. What other barriers to optimal treatment exist and which are potentially influenced by the provider? Naturally, we must respect patients’ preferences for treatment options. However, cognizant of the social and historical context in which preferences are formed, we should make the effort to elicit preferences that are authentic and ensure we have time to address patients’ preferences during each patient-provider encounter. References: (1) Rathore SS, Krumholz HM. Clarifying racial variation in health care use. Annals of Internal Medicine. 2004;141:635-638 [PMID: 15492343] (2) Katz JN. Patient preference and health disparities. JAMA. 2001;286:1506-1508 [PMID: 11572745] Authors: Adrian Kenny, Doris Duke Charitable Foundation Clinical Research Fellow, Harvard Medical School Elena Losina, PhD, Assistant Professor of Biostatistics, Boston University School of Public Health Jeffrey N. Katz, MD, MSc, Associate Professor of Medicine, Harvard Medical School, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital Address correspondence to: Adrian Kenny 260 Longwood Ave., MEC 233, PME-Cannon Society, Boston, MA 02115. adrian_kenny@student.hms.harvard.edu Conflict of Interest: None declared