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53
Infl uence of Patients’ Socioeconomic
Status on Clinical Management Decisions:
A Qualitative Study
ABSTRACT
PURPOSE Little is known about how patients’ socioeconomic status (SES) infl uences
physicians’ clinical management decisions, although this information may
have important implications for understanding inequities in health care quality.
We investigated physician perspectives on how patients’ SES infl uences care.
METHODS The study consisted of in-depth semistructured interviews with primary
care physicians in Connecticut. Investigators coded interviews line by line
and refi ned the coding structure and interview guide based on successive interviews.
Recurrent themes emerged through iterative analysis of codes and tagged
quotations.
RESULTS We interviewed 18 physicians from varied practice settings, 6 female,
9 from minority racial backgrounds, and 3 of Hispanic ethnicity. Four themes
emerged from our interviews: (1) physicians held confl icting views about the
effect of patient SES on clinical management, (2) physicians believed that
changes in clinical management based on the patient’s SES were made in the
patient’s interest, (3) physicians varied in the degree to which they thought
changes in clinical management infl uenced patient outcomes, and (4) physicians
faced personal and fi nancial strains when caring for patients of low SES.
CONCLUSIONS Physicians indicated that patient SES did affect their clinical management
decisions. As a result, physicians commonly undertook changes to their
management plan in an effort to enhance patient outcomes, but they experienced
numerous strains when trying to balance what they believed was feasible
for the patient with what they perceived as established standards of care.
Ann Fam Med 2008;6:53-59. DOI: 10.1370/afm.749.
INTRODUCTION
S
ocioeconomic status (SES) infl uences health care quality and outcomes.1-16
Patients of low SES receive fewer preventive services,1,6,8,12
worse diabetes care,1,2,15 and fewer indicated cardiac interventions.7,16
Moreover, SES disparities exist even among fully insured patients.4,5,8,13
Eliminating disparities in health and health care is a top priority of the
National Institutes of Health and one of the overarching goals of Healthy
People 2010.17,18
SES is a complex characteristic, generally understood to encompass
not only income and education level, the measures most commonly used,
but also a wide range of associated factors that may affect the quality of
health care patients receive, including insurance status, access to care,
patients’ health beliefs, and many facets of the doctor-patient relationship,
such as trust and communication.10,19,20-22 Little is known, however, about
how low SES ultimately infl uences physicians’ decision making regarding
clinical management of patients and thus how SES may contribute to measured
disparities in quality of care.
Susannah M. Bernheim, MD, MHS1,2
Joseph S. Ross MD, MHS3,4
Harlan M. Krumholz, MD, SM2,5,6,7
Elizabeth H. Bradley, PhD2,5
1
Department of Internal Medicine, Yale
University School of Medicine; and Performance
Management, Yale New Haven
Health System, New Haven, Connecticut
2
Robert Wood Johnson Clinical Scholars
Program, Department of Medicine, Yale
University School of Medicine, New
Haven, Connecticut
3
Department of Geriatrics and Adult Development,
Mount Sinai School of Medicine,
New York, New York
4
Geriatrics Research, Education and Clinical
Center, James J. Peter Veterans’ Administration
Medical Center, Bronx, New York
5
Division of Health Policy and Administration,
Department of Epidemiology and
Public Health, Yale University School of
Medicine, New Haven, Connecticut
6
Section of Cardiovascular Medicine,
Department of Medicine, Yale University
School of Medicine, New Haven,
Connecticut
7
Center for Outcomes Research and
Evaluation, Yale-New Haven Hospital,
New Haven, Connecticut
Confl icts of interest: none reported
CORRESPONDING AUTHOR
Susannah M. Bernheim, MD, MHS
Yale University School of Medicine
333 Cedar St
PO Box 208025
New Haven, CT 208088
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SOCIOECONOMIC STATUS AND CLINICAL DECISIONS
In the current health care environment, there
is increasing attention to individual physician performance
on discrete measures. Many have raised
concerns that those who provide care for vulnerable
populations, such as low-SES populations, may be at a
disadvantage in the context of public reporting of performance
measurement and pay-for-performance.23-26
Physicians’ perspectives on how SES affects clinical
management may offer some insight into the source of
current quality disparities, as well as inform ongoing
quality improvement efforts by highlighting specifi c
challenges to providing high-quality care for low-SES
populations. To understand better such perspectives,
we conducted in-depth semistructured interviews with
primary care physicians in Connecticut who care for
patients of low SES. We chose qualitative methods
to explore in rich detail recurrent themes regarding
physicians’ experiences caring for patients of low SES,
particularly their views about how SES infl uences both
the process of clinical care and patient outcomes.
METHODS
Study Design and Participants
We conducted a qualitative study, which uses methods
best suited for eliciting broad themes and patterns
when no previously described theoretical framework
exists.27,28 We undertook 18 semistructured interviews
with primary care physicians in Connecticut to elicit
their perceptions, beliefs, and experiences in caring for
patients of low SES. We chose this method of research
in the belief that physician participants were most
likely to respond candidly in the context of one-on-one
discussion with a physician interviewer.
To identify a sample of physicians who care for
patients of low SES, the population of primary care
physicians who provide care for Medicaid patients in
the state was used as a sampling frame. First, physicians
in this population were randomly identifi ed and contacted
for an interview. Fourteen physicians were initially
contacted and 11 agreed to an interview. Second,
physicians were purposefully selected from the Medicaid
pool to maximize variation on those characteristics
we believed might shape physicians’ perceptions
of caring for patients of low SES: race and ethnicity,
practice type (private practice, community health
center, academic practice), and practice setting (rural,
urban, suburban). Four additional physicians were contacted,
and all agreed to be interviewed. Last, we used
a snowball technique to identify minority physicians
and those caring for veterans who we believed were
underrepresented in our emerging sample.27 Three
physicians were identifi ed using this approach, and all
agreed to participate.
We provided written information about the project
to participants. Informed consent was completed
verbally to avoid producing written materials that
could be used to identify participants. Additionally,
any potentially identifying information given during
interviews was removed from transcripts. This project
was approved by the Institutional Review Board at
Yale University.
Data Collection
All interviews were conducted by a physician investigator—a
family physician (S.M.B.) or an internist
(J.S.R.). The interviews were semistructured, using an
interview guide composed of open-ended questions
and additional prompts. The interview guide was pilot
tested on 2 physicians from neighboring states before
starting the study. Interviews began with a broad question
asking how physicians thought patients’ SES infl uences
patient care.29 Physicians were further prompted
to give specifi c examples of changes in patient management
and encouraged to think about a range of ways
that SES infl uences care. We did not defi ne socioeconomic
status because we wanted to gain insight into
physicians’ own conception of SES and which factors
associated with SES they believed infl uenced patient
care management decisions. All participants completed
a brief written form describing their demographic
background, practice setting, and years of clinical
experience. Interviews were recorded and professionally
transcribed by an independent transcriptionist.
Data Analysis
We used line-by-line open coding to develop the coding
structure.27,28 Three investigators (S.M.B., J.S.R.,
E.H.B.) independently coded each transcript, tagging
sections of data with appropriate codes. After every 2
to 3 interviews, the researchers met to compare coding
and resolved differences with negotiated consensus. As
new concepts emerged, the code structure was refi ned
and the interview guide was modifi ed to refl ect emerging
themes, as is common in qualitative research.27,30,31
Periodically a member of the research team (S.M.B.)
reread previously coded transcripts and recoded using
the enhanced code structure to ensure earlier data were
fully analyzed. In addition, the research team reviewed
data within codes several times to ensure consistency
in their use and full understanding of their scope and
meaning. This process is consistent with the constant
comparative method27 or editing analysis.32 From this
process, recurrent themes emerged that characterized
the experiences of the participants. Additional interviews
were conducted until no new concepts emerged
with successive interviews, a process known as thematic
saturation.32 We selected verbatim quotations from the
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SOCIOECONOMIC STATUS AND CLINICAL DECISIONS
transcribed data to illustrate the recurrent themes using
Atlas-ti software (Scientifi c Software Development,
GmbH Berlin, version 5.0.67). Quotes were edited to
improve readability. A physician identifi cation number
is included after each quotation. Participating physicians
were contacted after the data analysis was complete
and given an opportunity to comment on the fi nal
themes that emerged from interviews. No substantive
changes were made during this process.
RESULTS
Participants (N = 18) included 6 women, 9 physicians
from minority racial backgrounds, and 3 of Hispanic
ethnicity (Table 1). Physicians’ clinical experience
ranged from 5 to 23 years, and they practiced in a
variety of settings: community clinic, private offi ce,
academic practice, and ambulatory care clinic within a
Veterans Affairs medical center. Two physicians were
family physicians, and the others were internists.
When asked to characterize their patients of
low SES, most physicians used specifi c descriptors,
although 2 physicians said that they could not generalize
about these patients as a group. We categorized
physicians’ descriptions into broader sets of attributes
(Table 2). These attributes included characterizations
based on not only economic and social factors, but also
on personality traits, life circumstances, and attitudes
and knowledge about medicine. Many words that physicians
used to describe their patients of low SES might
be considered negative (eg, distrustful, noncompliant);
others were more positive (eg, appreciative, interested
in health). Some used a combination of both positive
and negative descriptors. In addition to these characterizations,
4 recurrent themes emerged that together
portrayed the experiences of physicians caring for
patients of low SES: (1) they held confl icting views
about the effect of patient SES on clinical management;
(2) they believed that changes in clinical management
due to patient SES were made in the patient’s
interest; (3) they varied in the degree to which they
thought changes in clinical management infl uenced
patient outcomes; and (4) they faced personal and
fi nancial strains caring for patients of low SES.
Confl icting Views: SES and Clinical
Management
Some physicians indicated that patient SES substantially
infl uenced clinical management and that tailoring
care to account for SES was central to providing
high-quality care. As one said, “I need to understand
where they are and how to fi t their mold to help them
come up with the best possible outcome [physician
4].” Most physicians’ statements, however, divulged
more confl icted views about the infl uence of patient
SES on clinical management. A common tendency was
for physicians to report their belief that the “standard
of practice should not be [infl uenced] by low socioeconomic
status [physician 2].” Nevertheless, during
the course of the interviews, nearly all physicians
recounted circumstances in which the patient’s SES
Table 1. Characteristics of the Physician Sample
(N = 18)
Characteristic Value
Male, No. (%) 12 (67)
Age range, years 31-54
Race, No. (%)
White 9 (50)
Asian 6 (33)
African American/black 2 (11)
Other 1 (6)
Ethnicity, Hispanic, No. (%) 3 (17)
Patient practice, years 5-23
Patient composition, No. (%)
Uninsured 0-50
Medicaid 2-70
Veterans Affairs physicians, No. (%) 2 (11)
Practice setting, No. (%)
Urban 13 (72)
Suburban 4 (22)
Rural 1 (6)
Specialty, No. (%)
Internists 16 (88)
Family physicians 2 (11)
Table 2. Physician Descriptions of Patients
of Low Socioeconomic Status
Attributes
Examples of Descriptors
Used by Physicians
Economic Uninsured
Unemployed
On welfare
Sociocultural Minority race or ethnicity
Low educational achievement
Poor social networks
Personality traits Stoic
Guarded or distrustful
Appreciative
Life circumstances Chaotic lives
Involvement with substance abuse
Diffi culty with transportation
Attitude and knowledge
about medicine
Poor health literacy
Noncompliant
Poor health behaviors
Sicker or more acute visits
Interested in health
Unable to characterize
as a group
Everyone is different
No general statement about them
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SOCIOECONOMIC STATUS AND CLINICAL DECISIONS
did affect their clinical management decisions. Even
physicians who initially asserted that all patients in
their practice received identical care later described
differences based on patient SES. For instance, 1 physician
said at the beginning of an interview, “I see the
full gamut. I see the CEOs and then I see the neighborhood,
low-SES patients. And really, it is invisible to
me. They get the exact same approach and treatment
[physician 9].” Later in the same interview, however,
this physician described changing prescriptions and
reducing diagnostic testing because a patient had a
lower SES.
The prevailing sense that SES should not but nonetheless
does infl uence clinical management decisions
was expressed by this physician:
When we see a patient, we do not really think this patient
is from the poorer strata and [so we are] going to give him a
different medication. But when it actually comes to the practicality
of it, we have to, because he is not going to buy the
medication we have prescribed [physician 8].
Clinical Management Changes Made in
Patient’s Interest
Most of the changes physicians described as based on
a patient’s SES were made to provide care that was
more affordable, feasible, or comprehensible for a
patient. To make care more affordable to patients as a
result of income or insurance restrictions, for instance,
physicians described using less-expensive medications,
avoiding specialist referrals, trying to accomplish more
in a single visit, and postponing testing. Below a physician
describes treating a patient he thought had sleep
apnea but who could not afford a sleep study or a visit
to a sleep specialist:
So I put him on oxygen. … Right now, he is saying that
symptomatically he is feeling a little better. I still feel concerned
that we are treating it half-heartedly. This is not the
right treatment, but this is what we can do, and that is what
we are trying to do [physician 2].
In other cases a physician’s aim was to make care
more feasible given a patient’s lifestyle. Here a physician
describes matching a diabetic patient’s care to the
patient’s occupation and work schedule:
He was a trucker … we really had to tailor the medication.
He did not have any proper time to eat, and, you know, he
did not have time to come to his appointments. We have to
tailor his appointments according to his travel schedule. It is
not optimal, but we do the best we can [physician 8].
Additionally, to make care more comprehensible,
physicians described taking more time to communicate
fewer pieces of information or incorporating family
members into discussions because of concerns about
patients’ limited literacy. In another example a physician
described changing his style of speech to mirror
a patient’s in hopes of improving adherence and
outcomes:
Sit with me during an interview with a 26-year-old factory
worker. I don’t speak the same. I listen to him, I watch him,
I pace with him. I use his lingo, there is a lot of “dude,”
“buddy” kind of terminology. … Whatever I am trying to do
is always trying to impact the outcomes, because that is my
job [physician 11].
Clinical Management Changes and Infl uence
on Patient Outcomes
In some cases, physicians believed that, although they
provided different care for patients of low SES when
compared with patients of higher SES, patient outcomes
did not differ. For instance, physicians intimated
that prescribing a generic rather than a name brand
medication, changing communication styles, or eliminating
treatments of uncertain benefi t did not compromise
patient outcomes generally. One physician,
in fact, described what he viewed as excessive care for
more affl uent patients:
This patient comes in with pneumonia—patient A with good
[insurance]. Here’s your Lev-pack … nasal inhaler, especially
Advair. Here’s your guaifenesin with phenylephrine with
hydroxy-blah-blah-blah. Then patient B with no insurance.
Here’s your penicillin. Take deep breaths, 3 times a day,
cough hard, humidify at night, steam inhalation will help
you as well. So SES changes things. Patient A probably will
have all the unnecessary things that I give because I play
defensive. Patient B does just as well [physician 3].
In other cases, however, physicians indicated the
clinical management decisions made to accommodate
a patient’s low SES could compromise outcomes. One
physician described patient fi nances as limiting medication
choices and inevitably leading to worse outcomes
for the patient:
I’m a believer that with chronic pain you should use longeracting
narcotics, [but] our drug of choice is just too expensive
for him. … As a result, we have been forced to use lessexpensive
medications, and I’ve had great diffi culty getting
his pain under good control [physician 1].
Finally, physicians described tailoring care based on
a patient’s SES as a way to mitigate the negative impact
of SES on patient outcomes. The following physician
describes being less aggressive with diabetes treatment
as a means of enhancing outcomes for patients who
“because of the combination of their lack of insurance,
their understanding of the disease, and just what personal
diffi culties they are going through at the time”
will often not show up for long periods of time. This
physician contrasted his approach with that of his col-
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SOCIOECONOMIC STATUS AND CLINICAL DECISIONS
leagues who were infl exible in their treatment plans,
which he believed resulted in worse outcomes for
patients of low SES:
I think my care is affected because I know that at times if
I’m too rigid, the patients won’t come back …, [so we] try to
reach an understanding with the patients, and this way perhaps
there is a compromise of care, but the other side would
be that the patients would just be lost [physician 18].
Strains of Caring for Patients of Low SES
In changing their clinical management decisions to
account for a patient’s SES, physicians experienced
tension between an ideal of maintaining a consistent
standard of care for all patients and providing care that
was not the standard of care but what they believed
was appropriate given a patient’s SES. One way this
tension was conveyed was in physicians’ concern that
they may appear to be providing lower quality care to
patients of low SES, even when they believed it was in
a patient’s best interest:
I try to practice good medicine all the way through. But
sometimes when I am limited, it would seem like it is less
than good medicine. But it is still as appropriate as you can
get within the limits that you have [physician 15].
For some physicians concerns about not maintaining
standards of care and about worse patient outcomes
were compounded by increased attention to
performance measurement:
You are graded as a doctor by everybody in the world. Used
to be if you were a nice person and you practiced good medicine
that was enough, now you have to have data. What do
you do if the patient does not follow the game plan? There are
ways to try to coax the patients back in, but how much time
and energy do you have at the time [physician 11]?
In addition, physicians gave many examples of having
to work harder in an effort to maintain a standard
of care for patients of low SES. They spoke of putting
extra time into obtaining free medications or seeking
colleagues to accept specialty referrals and of adding
staff members to help patients of low SES navigate
the health care system. Furthermore, some physicians
stated that they could no longer afford to accept new
Medicaid or uninsured patients and questioned the
sustainability of the current health care system. As
one stated:
Being able to fi nd consultants, fi nd people to take care of
them, is very frustrating, and I think a lot of it comes down
to dollars and cents. It is very frustrating because it puts a
barrier right between you and the patient. And, you know,
lights have to be paid for, the staff has to be paid—if you are
not be able to do that, you are done. And so what do you
do? It is hard [physician 10].
Finally, physicians described being burdened by
fears about their level of responsibility for the infl uence
of patient SES on health care quality and outcomes:
If a patient comes in with adequate health care [coverage]
[and a blood pressure of] 190/100 mm Hg, you say, “Here,
I give you some medications to make sure that your blood
pressure goes down.” The patient with no money [and a
blood pressure of] 190/100 mm Hg, I give him some samples,
and then what? I give him a script. He does not have [the
medication because of costs]. I wonder after these 30 days,
after these pills, what is going to happen? Will I see him in
the newspaper obituary from a stroke [physician 16]?
DISCUSSION
Every physician within our diverse group described
situations in which they changed their care because of
a patient’s SES. What was particularly salient in these
physicians’ responses was that, although the physicians
described many of these changes as being in a patient’s
interest, physicians were nonetheless confl icted about
the concept that the patient’s SES infl uenced clinical
management. Their discomfort was in part due to concerns
that patients of low SES may experience worse
outcomes, but also it was due to the tension they faced
between tailoring care to make it more feasible and the
ideal of maintaining a standard of consistent care for all
patients. These fi ndings are relevant to understanding
health care disparities and the challenges of performance
measurement.
Many of the changes that physicians described—
less aggressive diabetes management, postponement
of testing, or use of less than ideal or nonstandard
treatments as a result of fi nancial limitations—may
contribute to observed disparities in health care quality.
Although interviewed physicians described changes in
clinical management as being made in a patient’s interest,
it is not clear whether these changes improve or
worsen patient outcomes. Some physicians argued that
they made changes to mitigate the impact of low SES,
whereas others believed that limits on care owing to
a patient’s SES inevitably led to worse outcomes. Our
fi ndings highlight the need to explore the how tailoring
patient care affects outcomes compared with care that
is blind to SES. These results also suggest that observed
disparities may in part result from physician actions
made in what they believe to be a patient’s interest.
Medical training and health policy are evolving
toward a concept of health care that is more patient
centered. Some changes made by physicians to accommodate
low SES, such as adapting communication to
improve understanding and adherence, align with the
priorities of patient-centered care.33-35 Importantly,
many others do not. Physicians frequently describe
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SOCIOECONOMIC STATUS AND CLINICAL DECISIONS
changing management in response to the fi nancial barriers
patients face. Tailoring care based on fi nancial
limitations, such as providing a less effective but more
affordable medication, may be appropriate, but it does
not necessarily refl ect the values or health beliefs of a
patient, as is central to most defi nitions of patient-centered
care. To confl ate changes made by a physician to
accommodate a patient’s socioeconomic circumstances
with those made in response to a patient’s values and
beliefs minimizes an important distinction, which is the
constraint physicians experienced when a patient’s SES
limited feasible care plans. This constraint was a source
of considerable stress to the physicians we interviewed.
Because physicians’ reimbursement is increasingly
based on standardized quality measures, the tension
experienced by physicians to balance standards and
feasibility is more poignant. Current quality measures
do not provide guidance or adjustment for the tailoring
of care that interviewed physicians believed best met
the needs of their patients. Although fi nancial limitations
commonly infl uence clinical practice, physicians
are without an evidence base to guide such decisions.
Some authors have suggested provocative ways that
SES might be appropriately incorporated into treatment
decisions, including consideration of education
level as a risk factor for cardiovascular disease and
accounting for education when prescribing preventive
medications, or changing cardiac intervention
decisions based on patients’ ability to afford medications.36,37
How such changes ultimately infl uence
patient outcomes needs further investigation.
Our interviews exposed the personal and fi nancial
strains that physicians experience when caring for
populations of patients of low SES. Many of the physicians
no longer accept Medicaid patients, a phenomenon
recently documented on a national level38; they
frequently spoke of burnout by those who provide care
to patients of low SES in the current health care environment;
and they fear the impact of payment linked
to performance measurement on their practice. As
national trends indicate, maintaining a physician workforce
willing to care for poor and vulnerable patient
groups is becoming more diffi cult,39 and our study suggests
a range of challenges that may be contributing.
There are several limitations to our study that
should be considered in its interpretation. First, we did
not use theoretical iterative sampling, in which earlier
interviews infl uence the subsequent selection of participants,30
and we limited our sampling frame to physicians
from a single state caring for adult patients only.
We did include, however, a diverse sample of Connecticut
physicians caring for patients of low SES so we
could obtain a broad range of perspectives. Second, we
interviewed only physicians; patients’ perspectives on
how SES infl uences clinical management may be different.
Although the scope of our fi ndings is limited to
the perspective of physicians, the purpose of our work
was to explore these perspectives as an initial contribution
to understanding the relationship between SES
and clinical management. Third, the interviewers were
primary care physicians with considerable experience
in caring for low-SES populations; their parallel education
and experience may have contributed to their ability
to establish rapport with the physicians interviewed
but may also have infl uenced both their approach to
the interviews and their interpretation of the data. For
this reason, all interviews were additionally coded by
a third investigator, a health services researcher with
substantial qualitative research experience and expertise
in quality of care.
Our fi ndings identify a number of ways that physicians
change care based on their patients’ SES. These
changes may contribute to measured socioeconomic
disparities in health care; however, many changes are
made to enhance patient outcomes given the constraints
associated with low SES. Explicit recognition
of the role of socioeconomic factors in clinical decision
making may be an important contribution in the
development of quality standards to ensure high-quality
care and a physician workforce willing to care for
vulnerable populations.
To read or post commentaries in response to this article, see it
online at http://www.annfammed.org/cgi/current/full/6/1/53.
Submitted February 13, 2007; submitted, revised, August 7, 2007;
accepted August 16, 2007.
Key words: Socioeconomic factors; healthcare disparities; quality of
healthcare; qualitative research
This work was presented at the North American Primary Care Research
Group (NAPCRG) Conference in Tucson, Arizona, October 16, 2006.
Funding support: Drs Bernheim and Ross were fellows in the Robert
Wood Johnson Clinical Scholars Program at Yale University supported
by the Robert Wood Johnson Foundation during time that work on this
project was ongoing. Dr Bernheim was also supported by a training
grant from the National Institutes on Aging (T32AG1934). Dr Ross is
currently supported by funding from the Hartford Foundation and by
Department of Veterans Affairs Health Services Research and Development
Service project grant TRP-02-149. Dr Bradley is supported by a
Catherine and Patrick Weldon Donaghue Medical Research Foundation
Investigator Award.
Acknowledgments: The authors thank Kevin Fiscella, MD, for his helpful
comments on an earlier version of this manuscript.
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