Physician Cognitive Processing as a Source of Diagnostic and Treatment Disparities in Coronary Heart Disease

Abstract

Literature on health disparities documents variations in clinical decision making by patient characteristics, physician attributes, and between healthcare systems. Using data from a vignette-based factorial experiment of 256 primary care providers, we examine the cognitive basis of disparities in the diagnosis and treatment of coronary heart disease (CHD). To determine whether previously observed disparities are due to physicians: (1) not fully considering CHD for certain patients or (2) considering CHD but then discounting it, half of physicians were explicitly directed to consider a CHD diagnosis. Relative to their unprimed counterparts, primed physicians were more likely to order CHD-related tests and prescriptions. However, main effects for patient gender and age remained, suggesting that physicians treated these demographic variables as diagnostic features amounting to lower risk of CHD for these patients. This finding suggests potential for physician appeals to perceived base rates to contribute to the further reification of socially constructed health statistics.

Examining Critical Health Policy Issues within and beyond the Clinical Encounter: Patient-Provider Relationships and Help-seeking Behaviors

“…Experiencing symptoms frequently prompts protective measures, including self-medication or restricting work or activities, and also denial or fears about consequences and costs that either delay treatment or discourage care altogether (Khrain and Carey 2009). Even when access, ability to pay, and symptom presentation are controlled, evidence shows persistent disparities in the types of treatments patients receive across categories of age, gender, race, and socioeconomic status (Lutfey et al 2010;McKinlay et al 2006;Bird et al 2007).…”

Provider and patient influences on the formation of socioeconomic health behavior disparities among pregnant women

“…Understanding how they begin provides a useful vantage point to intervene. This study builds on an emerging approach that emphasizes that advances in biomedicine may precipitate the formation of disparities in health behaviors and outcomes (Gortmaker and Wise 1997; Glied and Lleras-Muney 2008; Chang and Lauderdale 2009), and merges it with evidence of the role that health care providers play in influencing patient decisions (van Ryn and Burke 2000; Lutfey et al 2010; Osterberg and Blaschke 2011). …”

Diagnostic Certainty as a Source of Medical Practice Variation in Coronary Heart Disease: Results from a Cross-National Experiment of Clinical Decision Making

“…However, these questions are beyond the scope of the present study and these data do not allow us to specify the exact cognitive and psychological processes physicians use when interpreting information from the vignettes. A similar study of US physicians (with the same CHD vignette) primed physicians to determine whether the under-diagnosis of CHD in some patient populations was due to physicians not considering that diagnosis, or considering it and then eliminating it from their differential diagnosis (56). Also beyond the scope of this study, but potentially related, is the question of differences in clinical decision making practices between family practitioners and internists, despite both groups being likely to treat the type of patient depicted in the vignette.…”