In this study, access to HIV care—as measured by prolonged travel and wait times—was worse for blacks and Hispanics compared with whites. These findings are predominantly attributable to site-level characteristics. HIV care sites that provide services to a greater proportion of blacks and Hispanics may be more difficult to access for all patients.
These findings are consistent with prior research in non-HIV-infected minority populations suggesting that observed disparities in access to care may be more due to site-level or community effects (i.e., the local environment of a given HIV care site that affects access for all patients) than race, per se. In a nationally representative household survey conducted by the Department of Transportation, blacks spent a mean of 29 minutes traveling to their medical provider compared with 21 minutes for whites, though geographic distances to providers were comparable12
. In analysis of care of black and white Medicare recipients, 80% of black patients received care from 20% of U.S. providers and these providers reported having less access to healthcare resources than providers caring for predominantly white patients9
. In a large-scale study of several procedures undertaken at 123 hospitals, Hasnain-Wynia and colleagues31
concluded that observed racial differences in procedure rates were a result of where minority patients received care rather than bias or lack of cultural understanding. Baiker and colleagues examined disparities in healthcare utilization by race using Medicare claims data and found that differences in end-of-life care were far greater by residence than race10,32
. They conclude that efforts should be directed to improving quality of care across regions rather than across race. Blacks in many urban centers may be more likely to access general medical care at sites with more limited resources. Taken together, these studies and ours suggest that disparities in access to care by race may be explained more by differences in access for people living in predominantly minority vs. white communities (site-level effects) rather than for minority vs. white individuals within a given community (within-site effects). It is important to recognize that these community-level differences are no less problematic than individual-level differences. Creating more equitable healthcare access will likely require multi-faceted policy interventions that fund improvements in healthcare system and community infrastructure33
. For example, targeted supplemental funding for clinics treating predominantly minority populations might be used to create satellite services in local minority neighborhoods and hire additional staff to decrease wait times.
Blacks reported more positive experiences with patient–provider communication than whites. The relationship between patient-centered communication and race is complex. Patients’ ratings of provider communication were better among blacks than whites overall, an association that was little-affected by other sociodemographic factors. Prior studies have yielded conflicting findings regarding variations in communication satisfaction by race/ethnicity in general medical populations. Patient ratings of the quality of interpersonal communication were lower for minority patients than for whites in the Commonwealth Fund 2001 Health Care Quality Survey13
. In a telephone survey of persons with a recent primary care visit, Cooper et al. found that blacks reported lower satisfaction with participatory decision making14
. In a quantitative analysis of audiotaped patient–provider encounters during primary care visits, patient-centered communication scores were lower for black compared with white patients15
. In other studies, however, blacks reported comparable34
satisfaction with patient–provider communication than white patients. In the current study, the positive association between black race/ethnicity and communication ratings was reduced after addition of HIV care site to analytic models for three of four measures of patient-centered communication. This attenuation of effect was likely due to random variation in communication ratings across sites, since sensitivity analyses indicated that higher communication ratings among blacks could not be attributed to better provider communication at sites with higher proportions of black patients. Lurie et al. suggest that higher ratings of patient–provider communication may be the product of lower expectations for healthcare quality among blacks35
. As the HIV epidemic disproportionately affects persons of color in the U.S., further research is required to expand understanding of differences in patient–provider communication by race/ethnicity.
Results of this study should be interpreted in light of several potential limitations. First, we were unable to measure provider characteristics in this study and could not assess race concordance between patients and their providers. Previous studies suggest that patient–provider race concordance may be a better predictor of effective communication than patient race alone14,36,37
. Second, we were limited by self-reported measures of patient-centered access and communication in this analysis. Future studies that directly observe patient–provider encounters would be helpful in clarifying the relationship between race/ethnicity and patient-centered communication. Nonetheless, patients’ subjective views of their healthcare experiences are, by definition, necessary for developing more patient-centered healthcare systems. Third, the HIVRN is not a national probability sample. Though its sample is similar to that of a 1996 nationally representative sample of persons in care for HIV infection1,38
, we are cautious about generalizing our findings to the entire U.S. HIV-infected population. Finally, our sample should be interpreted as a convenience sample. Although it reflected the demographics of the larger HIVRN population, it is possible that patients who volunteered to be interviewed experienced systematically better (or worse) access and communication than non-participants. For example, rural residents from the South may have been less likely to participate due to prolonged travel times, and more likely to be black. Inclusion of such participants, however, would likely strengthen the magnitude and direction of our findings.
Patient-centered access to HIV care is lower for blacks and Hispanics compared with whites, while satisfaction with patient–provider communication is higher for blacks than other race/ethnicity groups. Location of care and population demographics, rather than individual patient characteristics, explain disparities in access. Policies seeking to develop a more patient-centered and equitable HIV healthcare delivery system should address the geographic location, staffing, and resources of clinics serving predominantly minority communities.
The HIV Research Network
Participating Sites Alameda County Medical Center, Oakland, California (Silver Sisneros, D.O.); Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (Richard Rutstein, M.D.); Community Health Network, Rochester, New York (Roberto Corales, D.O.); Community Medical Alliance, Boston, Massachusetts (James Hellinger, M.D.); Drexel University, Philadelphia, Pennsylvania (Sara Allen, C.R.N.P., Peter Sklar, M.D.); Johns Hopkins University, Baltimore, Maryland (Kelly Gebo, M.D., Richard Moore, M.D); Montefiore Medical Group, Bronx, New York (Robert Beil, M.D.); Montefiore Medical Center, Bronx, New York (Lawrence Hanau, M.D.); Nemechek Health Renewal, Kansas City, Missouri (Patrick Nemechek, D.O.); Oregon Health and Science University, Portland, Oregon (P. Todd Korthuis, M.D.); Parkland Health and Hospital System, Dallas, Texas (Philip Keiser, M.D.); St. Jude’s Children’s Hospital and University of Tennessee, Memphis, Tennessee (Aditya Gaur, M.D.); St. Luke’s Roosevelt Hospital Center, New York, New York (Victoria Sharp, M.D.); Tampa General Health Care, Tampa, Florida (Charurut Somboonwit, M.D.); University of California, San Diego, La Jolla, California (Stephen Spector, M.D.); University of California, San Diego, California (W. Christopher Mathews, M.D.); Wayne State University, Detroit, Michigan (Jonathan Cohn, M.D.)
Sponsoring Agencies Agency for Healthcare Research and Quality, Rockville, Maryland (Fred Hellinger, Ph.D., John Fleishman, Ph.D., Irene Fraser, Ph.D.); Health Resources and Services Administration, Rockville, Maryland (Alice Kroliczak, Ph.D., Robert Mills, Ph.D.)
Substance Abuse and Mental Health Services Administration, Rockville, MD (Kevin Mulvey, Ph.D., Pat Roth)
Data Coordinating Center Johns Hopkins University (Richard Moore, M.D., Jeanne Keruly, C.R.N.P., Kelly Gebo, M.D., Perrin Hicks, M.P.H., Michelande Ridoré, B.A.)