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To understand if patient–provider race-concordance is associated with improved health outcomes for minorities.
A comprehensive review of published research literature (1980–2008) using MEDLINE, HealthSTAR, and CINAHL databases were conducted. Studies were included if they had at least one research question examining the effect of patient–provider race-concordance on minority patients’ health outcomes and pertained to minorities in the USA. The database search and data analysis were each independently conducted by two authors. The review was limited to data analysis in tabular and text format. A meta-analysis was not possible due to the discrepancy in methods and outcomes across studies.
Twenty-seven studies met the inclusion criteria. Combined, the studies were based on data from 56,276 patients and only 1756 providers. Whites/Caucasians (37.6%) and Blacks/African Americans (31.5%), followed by Hispanics/Latinos (13.3%), and Asians/Pacific Islanders (4.3%) comprised the majority of the patient sample. The median sample of providers was only 16 for African Americans, 10 for Asians and two for Hispanics. The review presented mixed results. Of the 27 studies, patient–provider race-concordance was associated with positive health outcomes for minorities in only nine studies (33%), while eight studies (30%) found no association of race-concordance with the outcomes studied and 10 (37%) presented mixed findings. Analysis suggested that having a provider of same race did not improve ‘receipt of services’ for minorities. No clear pattern of findings emerged in the domains of healthcare utilization, patient–provider communication, preference, satisfaction, or perception of respect.
There is inconclusive evidence to support that patient–provider race-concordance is associated with positive health outcomes for minorities. Studies were limited to four racial/ethnic groups and generally employed small samples of minorities. Further research is needed to understand what health outcomes may be more sensitive to cultural proximity between patients and providers, and what patient, provider and setting-level variables may moderate or mediate these outcomes.
Despite improvements in the nation’s overall health, minorities continue to receive differential treatment in the American healthcare system. Considerable research has emerged highlighting the existence of racial/ethnic disparities resulting in minority patients receiving poor quality of care and experiencing poor outcomes among many health indices (Smedley et al. 2002). Many factors contribute to creating and sustaining health disparities including the influence of health system, utilization managers, patients, as well as bias, stereotyping, and clinical uncertainty on the part of healthcare providers (Smedley et al. 2002). Understanding pathways leading to racial/ethnic disparities in health continues to be a challenge. While many factors are believed to influence health disparities in racial/ethnic minorities, recent efforts have been directed toward understanding if patient–provider race-concordance may lead to improved health outcomes for minority patients.
The emergence of race-concordance concept within health disparities research represents a response to the enduring nature of health disparities and is an attempt to appeal to a basic social question, that is, are people able to identify, relate, understand, and interact more with those who may share their values and cultures? The hypothesis under girding race-concordance research is that racial/ethnic disparities in health may be ameliorated as a result of increased mutual respect, trust, communication, and satisfaction, which may exist more in race-concordant patient–provider relationships. Thus, the notion of concordance within healthcare embodies the idea of a therapeutic alliance between patients and providers (Bissell et al. 2004). The strength of such an alliance lies in the respect for patients’ agenda and the creation of openness in patient–provider relationship, so that both patients and providers can proceed to mutually agreed upon goals (Bissell et al. 2004).
Over the past two decades studies on race-concordance have failed to generate a general consensus on the association of race-concordance and improvement in health outcomes. The lack of clarity within the existing research heightens the importance of an analysis of this body of literature. To this end, the authors conducted a comprehensive review and analysis of the published research to answer the question, does patient–provider race-concordance matter in improving minority patients’ health outcomes?
A comprehensive review of published research literature was conducted using three bibliographic databases; Ovid MEDLINE (1980–2008), HealthSTAR (1980–2008), and CINAHL (1982–2008). A database search was conducted independently by two of the authors using key words race, ethnicity, concordance, or race-concordance. The search was limited to research articles with an abstract, published in English language. This independent review generated a list of 159 potentially relevant citations (Figure 1). The abstract of each of these 159 titles was reviewed independently by two authors. Studies were included if they had at least one study question examining the effect of patient–provider race-concordance on health outcomes pertaining to minority patients. Only articles published in the USA were considered. The inclusion was not limited based on the study design or sample size. Thus, both qualitative and experimental studies were included if they pertained to an actual or hypothetical minority patient population and addressed a research question about patient–provider race-concordance. Studies were excluded if the race-concordance research question did not pertain to at least one minority patient group, or pertained to minorities in non-health related settings (Weisse et al. 2005).
Thirty articles were identified that met the above inclusion criteria. An initial review of the articles was conducted by two of the authors to identify specific race-concordance outcome studied and grouped them according to meaningful outcome categories; six major categories emerged, that is, provision of healthcare, utilization of healthcare, patient–provider communication, patient satisfaction with provider of same race, patients’ preference for provider of same race, and perception of respect in race-concordant relationships. The studies that did not fit any of the above categories were grouped as ‘other studies’. These included selection of a regular physician (Gray and Stoddard 1997), interventionist race and change in caregiver depression or burden (McGinnis et al. 2006), and perceived medical errors (Stepanikova 2006). These studies were finally excluded as they studied diverse outcomes that could not be grouped under another meaningful category. After applying these inclusion and exclusion criteria, a list of 27 articles were selected for the final analysis.
The review was limited to data analysis in tabular and text format. A meta-analysis was not possible due to the discrepancy in methods and outcome measures between the studies. The quality of the articles was evaluated using a structured data extraction form generated based on the Agency for Healthcare Research and Quality guidelines to rate the strength of scientific evidence (AHRQ 2002). Studies were evaluated in five domains: (1) appropriateness of study question and design; (2) study sample; (3) comparability of subjects; (4) measurement of outcomes; and (5) appropriateness of study conclusions. Based on the main race-concordance conclusions, each study was coded as having ‘positive findings’, ‘negative findings’, or ‘mixed findings’. If a study found an association of race-concordance with outcome of interest for all minority groups included in that study, it was coded as a study with ‘positive finding’. If a study found no association of race-concordance with outcomes for any of the minority groups, the study was coded as with ‘negative findings’. Since our interest was to understand the effect of race-concordance for minorities, the authors still coded a study as having ‘negative’ support, if it found an association of race-concordance for only Whites/Caucasians but none of the minority patients. Finally, studies were characterized as yielding ‘mixed findings’ if there was partial support for race-concordance for certain outcomes or if the race-concordance was supported in some but not all minority groups included in a particular study. Each study was reviewed by two of the authors who independently completed the data extraction forms. The results were then compared and the numbers of discrepancies between the authors were recorded. All identified discrepancies were resolved with re-review of the articles and discussion between the authors. SPSS 13.0 was used to conduct a descriptive analysis of the pooled patient and provider sample from the included studies. If multiple studies were published using a single data source and had the same underlying sample, their sample size was counted only once to prevent double counting.
Twenty seven research publications of patient–provider race-concordance met our eligibility criteria. The specific concordance outcome and setting ranged widely across studies. Table 1 summarizes the sample characteristics, design, major findings and limitations of the included studies. The studies were heterogeneous with regard to the design and the data collection methods. Of the 27 studies, the majority (n= 15) were retrospective or employed a secondary analyses. Studies that used secondary analyses included data ranging from 1987 (Konrad et al. 2005) to 2001 (Blanchard et al. 2007). Four studies were qualitative (Garcia et al. 2003, Zayas et al. 2005, Gordon et al. 2006, Brown et al. 2007), three used cross-sectional surveys (Cooper-Patrick et al. 1999, Stevens et al. 2003, Lasser et al. 2005) and one collected data from actual patient–provider interactions (Tai-Seale et al. 2005). One was a prospective study (Cooper et al. 2003) and three used an experimental design using hypothetical vignettes (McKinlay et al. 2002, Bender 2007, Modi et al. 2007).
Table 2 presents the pooled analysis of the patient and provider sample by racial/ethnic categories. Combined, the studies included 56,276 patients and only 1756 health providers. The majority of the total patient sample was comprised of Whites/Caucasians and Blacks/African Americans (37.6 and 31.5%, respectively) followed by Hispanics/Latinos (13.3%), Asians/Pacific Islanders (4.3%), and ‘Other’ category (13.3%). Similarly, in the pooled analysis of the provider sample, Whites/Caucasians represented the predominant racial group (78.6%). Blacks/African Americans, Asians/Pacific Islanders and Hispanics/Latinos combined accounted for only 21% of the provider sample (10.9%, 8.9%, and 1.2%, respectively). Fourteen of the 27 studies (52%) did not include a provider sample as they relied on patients’ perceptions or self-report about provider of same race/ethnicity. The median sample for providers was only 16 African Americans, 10 Asians and two Hispanics (Table 2).
Of the 27 studies, patient–provider race-concordance was associated with positive health outcomes for minorities in only nine studies (33%), while eight studies (30%) found no association of race-concordance with the outcomes studied and 10 (37%) presented mixed findings (Table 1). In the nine studies that supported race-concordance, patient–provider race/ethnicity was associated with timely receipt of treatment (King et al. 2004), provision of more aggressive treatment (Modi et al. 2007), greater use of needed medical services (LaVeist et al. 2003) and preventive care (Saha et al. 2003, Lasser et al. 2005), improved communication and participatory decision making (Cooper-Patrick et al. 1999, Cooper et al. 2003), and preference for (Saha et al. 2000) and greater satisfaction with provider and healthcare (LaVeist and Carroll 2002, LaVeist and Nuru-Jeter 2002, Cooper et al. 2003).
To further understand what outcomes were sensitive to racial/ethnic proximity between patients and providers, the specific race-concordance outcome in each of the 27 studies were evaluated and grouped under a broad category of outcomes (Table 3). Some studies evaluated the association of race-concordance with more than one outcome (Malat 2001, Cooper et al. 2003, Saha et al. 2003, Schnittker and Liang 2006) and were grouped under more than one outcome category.
The most distinct pattern of findings emerged in the category of ‘provision of healthcare’ (n = 8) (Table 3). Except for two studies (King et al. 2004, Modi et al. 2007), none found an association of patient–provider race-concordance with outcomes in a variety of settings such as, appropriate assessment and diagnosis of medical conditions (McKinlay et al. 2002, Tai-Seale et al. 2005, Zayas et al. 2005), receipt of primary care services (Stevens et al. 2003, Stevens et al. 2005) or time spent during medical visit (Malat 2001). Although, Modi et al. found a positive association of race-concordance to provision of more aggressive treatment in patients with advanced dementia, this procedure may not particularly improve outcomes in this patient population (Modi et al. 2007).
Only two studies in the category of ‘utilization of healthcare’ found a positive association between patient–provider race-concordance and utilization of health services (Table 3). Patients in race-concordant relationships had lower missed appointment rates and were more likely to make their scheduled provider appointments (Murray-Garcia et al. 2001, Lasser et al. 2005).
Of note, about half the studies in both ‘provision’ (Malat 2001, Stevens et al. 2003, Stevens et al. 2005) and ‘utilization’ (Saha et al. 1999, LaVeist et al. 2003, Saha et al. 2003, Konrad et al. 2005) domains were based on patients’ (or parents in case of children) self-reports and did not include an objective measure of healthcare provision or utilization.
No clear pattern of findings emerged in the categories of ‘patient–provider communication’, ‘satisfaction’, and ‘perception of respect’, although they trended toward a positive association (Table 3). While a pattern of positive findings emerged in the category of patient satisfaction with provider of same race, three of these five studies were based on a single data source, that is, the 1994 Commonwealth Minority Health Survey, and employed non-mutually exclusive samples and outcomes (Saha et al. 1999, LaVeist and Carroll 2002, LaVeist and Nuru-Jeter 2002).
Similarly, three of the four studies of ‘patient preference’ for a race-concordant provider presented mixed findings. In one study, African-American males and females, and Spanish-speaking Latinos preferred providers of the same race and perceived that concordant relationships are important for quality of care, while Spanish-speaking Latinas did not hold this preference (Garcia et al. 2003). In two other studies the majority of the participants held no preference for a race-concordant provider relationship (Schnittker and Liang 2006, Bender 2007) even when they had a physician of the same race or ethnicity (Schnittker and Liang 2006).
In many studies, factors other than race-concordance such as, primary language (Clark et al. 2004), educational-concordance (Brown et al. 2007), site where care was received (Lasser et al. 2005), how well physician knew patient (Clark et al. 2004) and sustained relationship with provider (Konrad et al. 2005, Stevens et al. 2005) were more important predictors of patient outcomes.
Surprisingly, some studies found that race-concordance was associated with worse outcomes for minorities. For instance, Hispanics were more likely to report being treated with disrespect if in a concordant relationship with their providers (Blanchard et al. 2007). Further, only half of Blacks and Latinos believed that racism occurred less frequently in race-concordant interactions (Schnittker and Liang 2006). Tai-Seale et al. found a significantly lower likelihood of depression assessment among both racial and gender concordant dyads (Tai-Seale et al. 2005). The authors speculated that having a shared culture may possibly discourage detection and discussion of certain medical problems including mood and depression.
There is inconclusive evidence to support that race-concordance is associated with desirable outcomes for minorities. Only nine of the 27 studies reviewed found support for race-concordance. Even among these, some found only modest effect of race-concordance on outcomes (Lasser et al. 2005) and others (Saha et al. 2000, LaVeist and Carroll 2002, LaVeist and Nuru-Jeter 2002) were conducted using a single data source and did not have mutually exclusive respondent groups and outcomes. Notwithstanding the limitations of the body of literature and current analysis, the predominant finding in the category of healthcare provision suggests that having a provider of the same race does not particularly improve receipt of services for minorities. The studies under healthcare provision were heterogeneous with regard to outcomes and methods. Further, about half of the studies in both ‘provision’ and ‘utilization’ categories were based on patients’ self-report. While self-report is appropriate for some outcomes, such as patients’ preference and satisfaction, it may not be reliable for some other outcomes. Studies comparing agreement between self-report versus medical records for healthcare provision and utilization have found that reports of under or over utilization occur by individuals’ health status (Glandon et al. 1992), type of service (Glandon et al. 1992; Lubeck and Hubert 2005), and frequency of service used (Glandon et al. 1992). A recent study of health service utilization among marginalized population found poor agreement for ambulatory visits and laboratory tests performed and poor to fair agreement for medication use (Cunningham et al. 2007). Future studies may appropriately use an objective measure of health provision and utilization.
Interestingly, there are inconclusive results in minority patients’ preference, satisfaction, and communication domains. While there were only a small number of studies in each of these categories, studies of mixed findings raise concerns about either lack of power to detect true effect of race-concordance or true heterogeneity in the effect of race-concordance among subsets of minorities. For instance, the literature indicating mixed findings in the preference for racial/ethnic concordance may present a scenario where racial/ethnic alliance may be important only to a segment of population, possibly reflecting intra-group diversity in their expectations of healthcare providers and the treatments that they prescribe.
In some studies, race-concordance was associated with minority patients’ outcomes in combination with other factors such as language, length of patient–provider relationship or site of care. These findings suggest that race-concordance may be a heterogeneous construct and may stand as a proxy for a more complex dynamic embodying a combination of many patient, provider and system variables. This view of concordance allows future studies to carefully consider interactions of race-concordance with other patient, provider and setting-level variables critical to a more nuanced examination of this concept.
A number of factors ought to be considered in evaluating the relevance of the concept of patient–provider race-concordance within the US healthcare context. First, the issue of race/ethnicity is complex on several levels, and the existing research does not appear to capture these complexities. Invariably, the studies were limited to only four racial/ethnic groups: Whites, Blacks, Hispanics and Asians, with Whites and Blacks representing over two-thirds of the patient and provider samples. The US Census Bureau collects data on six racial categories including: (1) White; (2) Black or African American; (3) American Indian/Alaska Native; (4) Asian; (5) Native Hawaiian/Pacific Islander; and (6) Some other race (US Census Bureau 2001). ‘Race’ and ‘Hispanic origin’ represent two separate concepts, as Hispanics may belong to any of the six racial categories or to multiple races (US Census Bureau 2000). This distinction was missing in a number of studies analyzed.
In the last US Census held in 2000, the Census Bureau, for the first time, permitted marking of ‘more than one race’ to capture an increasing number of people who identify themselves as multiracial: 6.8 million people identified themselves as belonging to more than one race; of these, 11.5% were both White and Black, 12.7% were both White and Asian, and 32.3% reported being White and ‘Some other race’ (US Census Bureau 2001). Sixty-three possible race combinations exist for the six basic racial categories and 57 categories for those who report two or more races (US Census Bureau 2000). Thus, it is not clear how the racial/ethnic concordance literature may relate to minorities who are biracial or multiracial.
Finally, the underlying assumption of the racial/ethnic concordance literature is that patients and providers are able to identify with people of similar race/ethnicity who may look like them or share similar language or culture. This approach undermines the vast heterogeneity that exists within some racial groups. For instance, the ‘Asian’ category in the US census includes subcategories ranging from Koreans to Asian Indians. These so-called ‘Asian’ subcultures are as removed from each other as any other major racial groups, thus raising a question about the relevance of the concept of concordance to the subsets of minorities.
Further, the race-concordance literature should also be evaluated in the light of limitations pertaining to minority providers. First, a majority of the studies in this review was conducted with the physician providers, thus limiting understanding of the implications of race-concordance concept for other health providers, for example, nurse practitioners, who increasingly manage patients in a variety of healthcare settings. Further, about half the studies did not include a provider sample as they relied on patients’ self-report and perceptions about providers of same versus different race/ethnicity. Even among the studies that included a provider sample, minority providers were particularly low, possibly due to the serious shortage of minority health providers in the US health system. While Hispanics, non-Hispanic African Americans and American Indians represent over 27% of the US population (US Census Bureau 2007), less than 9% of nurses, 6% of physicians, and 5% of dentists are from these racial/ethnic groups (Sullivan 2004). The level of minorities in the workplace is expected to decrease due to the low levels of underrepresented minorities enrolled in health professional schools (Sullivan 2004).
The issue of newly migrant health professionals further complicates the issue of race-concordance. The American Association of Medical Colleges estimate that 5% of immigrants have entered medical schools and a majority of these physicians will remain in the USA permanently after graduation (AAMC 2005). About 14% of nurses and 20% of physicians in the USA are from foreign countries (Brush et al. 2004, AAMC 2005). It is expected that with the current workforce shortage, the majority of current vacancies are more likely be filled by foreign nurses and physicians. This introduces the issue of generational congruence in the debate of racial/ethnic concordance. For instance, would the race-concordance concept be relevant for patients and providers with racial concordance but generational discordance and differences in the levels of acculturations?
On a normative level, the problem with the concept of race-concordance is that it can potentially create a perception that only the providers of same race or ethnicity are best suited to provide appropriate or effective healthcare. Race is, after all, a social construct. Focusing on race-concordance could potentially create a racially segregated healthcare system and may perpetuate stereotypes and generalizations about how certain minority groups ought to be treated. Thus, it is imperative that the findings of race-concordance literature and future efforts be examined in the light of the above normative risks including a racially segregated health delivery system. It may be argued that increasing diversity in the healthcare professions is a laudable goal and should be pursued regardless of the tangible ends it may serve.
The authors are unaware of any prior comprehensive reviews on this topic. Nevertheless, this review has several limitations. The data analysis was limited to tabular and text format due to heterogeneity in methods and outcomes between studies as well as smaller numbers of studies within each outcome category. A meta-analysis may be conducted as data accumulates on the topic. Because this review was limited to tabular and descriptive analysis, qualitative studies were not excluded. Due to the nature of qualitative research, these studies typically had small sample sizes. Thus, median sample and range are reported for the pooled sample for each minority group. Future studies undertaking a meta-analysis may appropriately exclude qualitative studies or use synthesis technique appropriate to qualitative data. While two authors independently categorized studies and compared findings, the results of this review may be confounded by how studies were assigned to individual outcome category. Finally, this analysis included only published studies.
Many gaps remain in our understanding of if, why, and how patient–provider race-concordance may influence minority patients’ outcomes, what health outcomes may be more sensitive to cultural proximity between patients and providers, and what patient, provider and setting-level variables may mediate or moderate these outcomes? These questions can guide researchers whose goals are to understand and dismantle health inequalities among many racial/ethnic minority populations. There is also a need to evaluate the concept of race-concordance while considering the limitations of this body of research, normative risks, and practical realities of the minority workforce in the US health care system.