Neil R. Powe, Lisa A. Cooper
Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance, Lisa A. Cooper and Neil R. Powe, The Commonwealth Fund, July 2004
While Hispanics, African Americans, and Native Americans represent more than 25 percent of the U.S. population, they comprise fewer than 6 percent of doctors and 9 percent of nurses. Minority patients frequently are treated by professionals from a different ethnic background in so-called race-discordant relationships. Many research studies provide a strong rationale for increasing diversity among health professionals. They document ongoing racial and ethnic disparities in health care and also link race or ethnic concordance in the patient–physician relationship to health care processes and outcomes. This literature on ethnic discordance has implications for health policy, health care delivery, medical education, and future research.
Based on this research, the authors recommend that health policy be revised to encourage workforce diversity by funding programs that support the recruitment of minority students and medical faculty. To improve clinical practice and health care delivery, health systems should optimize their providers' ability to establish rapport with minority patients. Cultural competency training should be incorporated into the education of health professionals. Finally, future research should provide additional insight into the mechanisms by which concordance of patient and physician race, ethnicity, and language affects processes and outcomes of care.
Many studies of patient–provider race concordance grew out of the debate over whether increasing the number of ethnic minority health professionals would reduce health care disparities for ethnic minorities. For 20 years, this debate has largely been informed by a significant body of literature that examined the role of ethnic minority physicians in caring for underserved populations. This report describes the literature on patient–provider concordance with regard to race, ethnicity, and language. Most of the studies use data collected from primary care physicians or patients who report receiving care from primary care physicians. The authors review the literature on patient–provider concordance with regard to race and ethnicity and compare and contrast these findings to the literature on patient–provider language concordance. To contextualize these studies in the field of health care disparities, they present a conceptual framework for the relation of race, ethnic, and language concordance with health care processes and outcomes.
Recent studies on how patients rate the quality of care they receive from physicians have described differences between race-concordant and race-discordant patient–physician relationships. Patients in race-concordant relationships with their physicians rated their physicians' decision-making styles as significantly more participatory and their care more satisfactory overall than patients in race-discordant relationships.
A Commonwealth Fund–supported study used measures of actual communication behaviors of physicians and patients to compare patient–physician communication in race-concordant and race-discordant relationships, and examined whether communication behaviors explain differences in patient ratings of satisfaction and participatory decision-making (Cooper 2003). The study found that race-concordant visits were longer and had higher ratings of patient positive affect than race-discordant visits. Patients in race-concordant visits were also more satisfied, and rated their physicians as more participatory, regardless of the communication that occurred during the visit. The authors concluded that because the association between race concordance and higher patient ratings of care is independent of patient-centered communication, other factors such as patient and physician attitudes may mediate the relationship. They also suggested that the best strategies to improve health care experiences for ethnic minorities are to increase ethnic diversity among physicians and engender trust and comfort between patients and physicians of different races.
Few studies have examined the impact of patient–physician race concordance on health service utilization or health outcomes. There is reasonable evidence that patient–provider race concordance is associated with better patient ratings of care among adult primary care patients. There is some evidence that race concordance is associated with examples of better patient–physician communication, such as longer visits. There is also limited evidence that race concordance is associated with better health outcomes, as only one study examined this issue. It found that clinicians in race discordant relationships gave patients lower ratings of clinical improvement in only one of 15 health outcomes (Rosenheck 1995). Regardless of whether race concordance is linked to health outcomes, there is support for the notion that increasing racial and ethnic diversity among physicians will provide ethnic minority patients with more choices and better experiences with care processes, including positive affect, longer visit duration, higher patient satisfaction, and better participation in care.
Studies of concordance of other sociocultural indicators—such as language and the limited ability to speak English—may provide insight into the mechanisms of race concordance. The literature focuses on how patient–provider language concordance is related to several factors, including the use of interpreter services and health outcomes for patients with limited proficiency in English.
Collectively, this research lays the foundation for interventions that target the improvement of patient–provider relationships across racial and ethnic lines throughout the health care system. These interventions are an important strategy for eliminating racial and ethnic health disparities.