Racial Disparities in Patient-Reported Measures of Physician Cultural Competency Among Cancer Survivors in the United States | Health Disparities | JAMA Oncology | JAMA Network
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Figure.  Rates and Multivariable Adjusted Odds Ratiosa of Patient-Reported Measuresb of Physician Cultural Competencyc
Rates and Multivariable Adjusted Odds Ratiosa of Patient-Reported Measuresb of Physician Cultural Competencyc

The data were stratified by patient race/ethnicity among 2244 adult cancer survivors included in the 2017 National Health Institute Survey (NHIS). The non–Hispanic white group served as the referent. A, For the belief that physicians sharing or understanding culture was very/somewhat important, the adjusted odds ratio (AOR) for nonwhite minority cancer survivors was 1.92 (95% CI, 1.46-2.52; P < .001). B, For access to culturally competent physicians, the AOR for nonwhite minority cancer survivors was 0.42 (95% CI, 0.26-0.66; P < .001). For always/most of the time receiving respectful treatment, the AOR was 0.93 (95% CI, 0.47-1.83; P = .83). For receiving easily understandable health information the AOR was 1.15 (95% CI, 0.70-1.90; P = .57), and for being asked about opinions or beliefs regarding care, 1.03 (95% CI, 0.78-1.36; P = 0.85). The error bars represent 95% CIs.

aIn addition to race/ethnicity, the models were also adjusted for age (continuous), sex (male vs female [referent]), sexual orientation, (heterosexual/“straight, that is, not lesbian or gay” [referent] vs lesbian, gay, bisexual, or “something else” vs unknown [including responses of “I don’t know”]), citizenship status (US citizen [referent] vs non US citizen vs unknown), country of birth, (US born in 50 states [referent] vs all other birthplaces vs unknown), language spoken during NHIS interview, (English only [referent] vs any non-English), family income-to-poverty ratio (<1.00 vs 1.00-1.99 vs 2.00-3.99 [referent] vs ≥4.00), primary source of insurance, (private [referent] vs Medicare vs military based vs Medicaid vs uninsured [including Indian Health Services and Single-Service plans] vs unknown), highest education level attained, (less than high school vs high school diploma/GED vs some college vs college degree or greater [referent]), marital status (married/living with partner [referent] vs separated/widowed vs unknown), US geographic region, (Northeast [referent] vs Midwest vs South vs West), self-reported health status, (excellent vs very good vs good [referent] vs fair vs poor vs unknown), and place of usual care when sick (doctor’s office/health center/outpatient clinic/health maintenance organization/urgent care/walk-in clinic [referent] vs emergency department/other/unknown). There were no respondents with unknown variables of age or sex. Analyses were adjusted for 2 respondents with unknown race/ethnicity category.

bSurvey question 1 (excluding 13 nonresponders): “Some people think it is important for their providers to understand or share their race or ethnicity or gender or religion or beliefs or native language. How important is it to you that your health care providers understand or are similar to you in any of these ways?” Respondents selected from 4 possible answers: “very important,” “somewhat important,” “slightly important,” or “not important at all.” Answers were binarily categorized a priori as “very important”/“somewhat important” vs “slightly important”/“not important at all.” Survey question 2 (excluding 24 nonresponders and 1263 participants not asked this question by the NHIS given response of “not important at all” in question 1): “How often were you able to see health care providers who were similar to you in any of these ways?” For questions 2 to 5, respondents selected from 4 possible answers: “always,” “most of the time,” “some of the time,” or “none of the time.” Answers were binarily categorized as “always”/“most of the time” (ie, frequently) vs “some of the time”/“none of the time.” Survey question 3 (excluding 4 nonresponders): “How often were you treated with respect by your health care providers?” Survey question 4 (excluding 4 nonresponders): “How often did your health care providers tell or give you information about your health and health care that was easy to understand?” Survey question 5 (excluding 14 nonresponders): “How often did your health care providers ask for your opinions or beliefs about your medical care or treatment? For example, what kind of tests, procedures, or medications you prefer.”

cThe NHIS defined culture as “any race or ethnicity or gender or religion or beliefs or native language.”

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Polite  BN, Adams-Campbell  LL, Brawley  OW,  et al.  Charting the future of cancer health disparities research: a position statement from the American Association for Cancer Research, the American Cancer Society, the American Society of Clinical Oncology, and the National Cancer Institute.  Cancer Res. 2017;77(17):4548-4555. doi:10.1158/0008-5472.CAN-17-0623PubMedGoogle ScholarCrossref
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Ward  E, Jemal  A, Cokkinides  V,  et al.  Cancer disparities by race/ethnicity and socioeconomic status.  CA Cancer J Clin. 2004;54(2):78-93. doi:10.3322/canjclin.54.2.78PubMedGoogle ScholarCrossref
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Winkfield  KM, Flowers  CR, Patel  JD,  et al.  American Society of Clinical Oncology strategic plan for increasing racial and ethnic diversity in the oncology workforce.  J Clin Oncol. 2017;35(22):2576-2579. doi:10.1200/JCO.2017.73.1372PubMedGoogle ScholarCrossref
4.
Winkfield  KM, Flowers  CR, Mitchell  EP.  Making the case for improving oncology workforce diversity.  Am Soc Clin Oncol Educ Book. 2017;37:18-22. doi:10.14694/EDBK_100010PubMedGoogle ScholarCrossref
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Centers for Disease Control and Prevention. National health interview survey: methods. https://www.cdc.gov/nchs/nhis/methods.htm. Accessed July 1, 2018.
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Blewett  LA, Rivera Drew  JA, Griffin  R, King  ML, Williams  KCW. IPUMS health surveys: national health interview survey, version 6.3. https://ipums.org/projects/ipums-health-surveys/d070.v6.3. Accessed September 19, 2019.
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    Research Letter
    October 31, 2019

    Racial Disparities in Patient-Reported Measures of Physician Cultural Competency Among Cancer Survivors in the United States

    Author Affiliations
    • 1Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
    • 2Department of Radiation Oncology, Wake Forest, Winston-Salem, North Carolina
    • 3Division of Biostatistics, Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
    • 4Department of Medicine, Massachusetts General Hospital, Boston
    • 5Dana-Farber Cancer Institute, McGraw/Patterson Center for Population Sciences, Boston, Massachusetts
    • 6Department of Medical Oncology, University of Texas Southwestern, Dallas
    JAMA Oncol. 2020;6(1):152-154. doi:10.1001/jamaoncol.2019.4720

    Racial disparities in cancer incidence and outcomes have been well documented1,2 and may be due in part to lack of physician cultural competency. A cancer diagnosis and discussions of prognosis and treatments can have widely different implications across different cultural contexts. Highlighting the importance of high-quality care for diverse cultures, the American Society of Clinical Oncology recently outlined goals for improving cultural competency within its policy statement on cancer disparities.3,4 However, nationally representative data on cultural competency among physicians is limited. We therefore examined patient–reported physician cultural competency among cancer survivors in the United States using data from a contemporary population-based survey.

    Methods

    The National Health Interview Survey (NHIS) collects data on a range of health indicators for noninstitutionalized, civilian adults.5 In 2017, the NHIS included a supplemental set of questions regarding physician cultural competency (eg, “How often were you treated with respect by your providers?”) (Figure). Harmonized data of participants reporting a cancer diagnosis were obtained through the Integrated Health Interview Series.6

    Multivariable logistic regression defined adjusted odds ratios (AORs) with 95% CIs for each patient-reported measure of cultural competency across respondent reported race/ethnicity (non–Hispanic white [referent] vs nonwhite minority [either Hispanic/Latino ethnicity or nonwhite race]), among other sociodemographic variables (Figure). Subpopulation sample weighting defined nationally representative estimates for all end points. Statistical testing was 2-sided (α = .05) and was performed with Stata/SE 15.1 (StataCorp). The University of Texas Southwestern Institutional Review Board deemed the study exempt from review and patient informed consent requirements because deidentified data were used.

    Results

    Among 2244 adult cancer survivors who responded to the survey supplement, 1866 (81.8% [sample weighted]) were non–Hispanic white, 2 (<0.1%) had unknown race/ethnicity, 1334 (59.4%) were women, and the median age was 68 years (interquartile range, 59-76 years). Nonwhite minority cancer survivors were more likely than non–Hispanic white cancer survivors to report that it was somewhat/very important for their physicians to share or understand their culture (49.6% [n = 177 of 372] vs 31.2% [n = 577 of 1857; sample weighted; excluding 13 nonresponders]; AOR, 1.92; 95% CI, 1.46-2.52), but were less likely to report frequently being able to see physicians who shared or understood their culture (65.3% [n = 133 of 200] vs 79.9% [611 of 755; excluding 24 nonresponders and 1263 participants not asked this question given the response of “not important at all” for question 1]; AOR, 0.42; 95% CI, 0.26-0.66) (Figure). Notably, 12.6% of nonwhite minority cancer survivors (n = 25 of 200) were never able to see physicians who shared or understood their culture, compared with 4.0% of non–Hispanic whites (n = 28 of 755) (AOR, 4.10; 95% CI, 2.01-8.35). Both minority and non–Hispanic white cancer survivors reported similarly high rates of frequently being treated with respect by physicians, receiving easily understandable health information from their physicians, and being asked by physicians for their opinions or beliefs regarding care (Figure).

    Discussion

    Using national population-based data, our study suggests that minority cancer survivors appear to place greater value on physician cultural competency but are less likely to be cared for by those who share or understand their culture. This disparity could be attributed in part to the limited diversity of the oncology workforce, which is currently comprised of 5.3% black/African American and Hispanic/Latino physicians.2 Our findings could also be explained by insufficient training in cultural competency—irrespective of physician background—geographic variations in physician availability, insurance plan coverage networks, and potential preferences of physician characteristics other than cultural competency that some patients may value more. Limitations include lack of information on physician race/ethnicity precluding analysis of patient-physician racial concordance, lack of data describing whether a respondent’s primary physician was an oncologist or physician—although most cancer survivors continue seeing their oncologist longitudinally—and possible response biases given the study’s survey design.

    In summary, despite longstanding efforts to improve care for minority patients with cancer and cancer survivors, there remain racial/ethnic disparities in receipt of culturally competent care. These findings should provide an impetus for evaluation of policy and guidelines designed to improve oncology training in cultural literacy.

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    Article Information

    Accepted for Publication: August 29, 2019.

    Corresponding Author: Nina N. Sanford, MD, Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Rd, Dallas, TX 75390-9303 (nina.sanford@utsouthwestern.edu).

    Published Online: October 31, 2019. doi:10.1001/jamaoncol.2019.4720

    Author Contributions: Dr Sanford and Mr Butler had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Mahal and Sanford contributed equally as co–senior authors.

    Study concept and design: Butler, Mahal, Sanford.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Butler, Mahal, Sanford.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Butler, Ahn, Mahal, Sanford.

    Obtained funding: Song, Mahal.

    Administrative, technical, or material support: Mahal.

    Study supervision: Dee, Mahal, Sanford.

    Other—Interpretation of results: Song.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: Dr Mahal reports funding from the American Society of Radiation Oncology and the Prostate Cancer Foundation.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Polite  BN, Adams-Campbell  LL, Brawley  OW,  et al.  Charting the future of cancer health disparities research: a position statement from the American Association for Cancer Research, the American Cancer Society, the American Society of Clinical Oncology, and the National Cancer Institute.  Cancer Res. 2017;77(17):4548-4555. doi:10.1158/0008-5472.CAN-17-0623PubMedGoogle ScholarCrossref
    2.
    Ward  E, Jemal  A, Cokkinides  V,  et al.  Cancer disparities by race/ethnicity and socioeconomic status.  CA Cancer J Clin. 2004;54(2):78-93. doi:10.3322/canjclin.54.2.78PubMedGoogle ScholarCrossref
    3.
    Winkfield  KM, Flowers  CR, Patel  JD,  et al.  American Society of Clinical Oncology strategic plan for increasing racial and ethnic diversity in the oncology workforce.  J Clin Oncol. 2017;35(22):2576-2579. doi:10.1200/JCO.2017.73.1372PubMedGoogle ScholarCrossref
    4.
    Winkfield  KM, Flowers  CR, Mitchell  EP.  Making the case for improving oncology workforce diversity.  Am Soc Clin Oncol Educ Book. 2017;37:18-22. doi:10.14694/EDBK_100010PubMedGoogle ScholarCrossref
    5.
    Centers for Disease Control and Prevention. National health interview survey: methods. https://www.cdc.gov/nchs/nhis/methods.htm. Accessed July 1, 2018.
    6.
    Blewett  LA, Rivera Drew  JA, Griffin  R, King  ML, Williams  KCW. IPUMS health surveys: national health interview survey, version 6.3. https://ipums.org/projects/ipums-health-surveys/d070.v6.3. Accessed September 19, 2019.
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