Prevalence and overlap of childhood and adult physical, sexual, and emotional abuse: a descriptive analysis of results from the Boston Area Community Health (BACH) survey.

Abuse is associated with a wide variety of health problems, yet comprehensive population-based data are scant. Existing literature focuses on a single type of abuse, population, or lifestage. Using a racially/ethnically diverse community-based sample, we document the prevalence of physical, emotional, and sexual abuse by lifestage and gender, assess variation in abuse by sociodemographics; establish overlap of abuses; and examine childhood abuse relationships with abuse in adulthood. Prevalence of abuse ranges from 15% to 27%; women report more adulthood emotional abuse and lifetime sexual abuse than men; reports of abuse can vary by race/ethnicity and poverty status, particularly in women; there is overlap between types of abuse; and a history of childhood abuse is associated with a greater risk of abuse as an adult.

Examining critical health policy issues within and beyond the clinical encounter: patient-provider relationships and help-seeking behaviors.

Among notable issues in health care policy and practice over the past 50 years have been those centered on the changing dynamics in clinical encounters, predominantly the relationship between physicians and patients and access to health care. Patient roles have become more active, diverse, long-term, and risk-based, while patient-provider relationships are multifaceted, less paternalistic, and more pivotal to health outcomes. Extensive literatures on help-seeking show how much social influences affect both undertreatment and inappropriate high utilization of health care. The challenge in trying to contain the growth of health care costs is two-fold: developing better ways of defining need for care and promoting better access for those who could benefit most from health care. Both of these strategies need to be considered in the context of addressing racial, ethnic, socioeconomic, and health status disparities. Rebuilding the primary care sector as a sociologically informed strategy and a key component of health care reform may optimize both health care delivery and patient outcomes.

Physician cognitive processing as a source of diagnostic and treatment disparities in coronary heart disease: results of a factorial priming experiment.

Literature on health disparities documents variations in clinical decision-making across patient characteristics, physician attributes, and among health care 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). We explore 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 the physicians in the experiment were primed with explicit directions to consider a CHD diagnosis, and half were not. Relative to their unprimed counterparts, primed physicians were more likely to order CHD-related tests and prescriptions. However, the main effects for patient gender and age remained, suggesting that physicians treated these demographic variables as diagnostic features indicating lower risk of CHD for these patients. This finding suggests that physician appeals to perceived base rates have the potential to contribute to the further reification of socially constructed health statistics.

Prevalence and correlates of sexual activity and function in women: results from the Boston Area Community Health (BACH) Survey.

Relatively few studies have measured sexual functioning in women using a large, diverse, community-based sample with measures that allow for direct comparisons with previous findings. In this article, we: (1) describe prevalence of sexual activity in women by key sociodemographic characteristics, including age, race/ethnicity, marital status, and socioeconomic status; and (2) estimate the influence of key correlates on sexual problems. Data were analyzed from the Boston Area Community Health (BACH) Survey, a 2002-2005 community-based epidemiologic study of urologic and gynecologic symptoms, sociodemographics, health status, and psychosocial characteristics in a diverse sample of Boston area residents (N = 3,205 women aged 30-79 years). Analyses of sexual activity prevalence and reasons for inactivity were conducted on the full sample, while analyses of sexual problems and their correlates were conducted for the subset of women who engaged in sexual activity with a partner in the previous 4 weeks. A total of 49% of participants were not sexually active, citing lack of interest (51.5%) and lack of a partner (60.8%) as the most common reasons. Data pertaining to five dimensions of sexual functioning were gathered through a self-administered questionnaire adapted from the Female Sexual Function Index, measuring desire among all women and arousal, lubrication, orgasm, and pain among those who were sexually active. Among the sexually active, we obtained a 38.4% prevalence rate of sexual problems and 34.9% of those participants reported that they were also dissatisfied with their sex lives. Therefore, only 13.7% of the sexually active sample exhibited both sexual problems and dissatisfaction with their overall sex lives. Age was strongly and positively associated with sexual problems. In terms of psychosocial factors, depression, sexual and physical abuse in adulthood, global mental health functioning, and alcohol were associated with sexual problems, with variation across racial/ethnic groups.

Is certainty more important than diagnosis for understanding race and gender disparities?: an experiment using coronary heart disease and depression case vignettes.

OBJECTIVES: To (1) examine the influence of patient and provider attributes on physicians' diagnostic certainty and (2) assess the effect of diagnostic certainty on clinical therapeutic actions. METHODS: Factorial experiment of 128 generalist physicians using identical clinically authentic videotaped vignettes depicting patients with coronary heart disease (CHD) or depression. RESULTS: For CHD, physicians were least certain for Black patients (p=.003) and for younger female patients (p=.013). For depression, average certainty was higher than for the CHD presentation (74.0 vs. 57.9 on of scale of 0-100, p<.001) and there were no main effects of patient or provider characteristics. Increasing diagnostic certainty was a significant predictor of subsequent clinical actions, and these varied according to physician and patient characteristics across both conditions. CONCLUSIONS: Physicians were least certain of their CHD diagnoses for Black patients and for younger women, but patient characteristics alone did not affect physician certainty of depression diagnoses. Physicians responded differentially to diagnostic certainty in terms of their clinical therapeutic actions such as test ordering and writing prescriptions. Physician responses to certainty may be as important as their responses to patient characteristics for understanding variation in clinical decision-making.

What happens along the diagnostic pathway to CHD treatment? Qualitative results concerning cognitive processes.

Extensive research on health disparities documents persistent differential diagnosis and treatment of many conditions according to patient characteristics, physician attributes, and healthcare systems. Less is known about how physicians arrive at their decisions. We use qualitative data from a vignette-based factorial experiment to examine how physicians reason through and account for their clinical decisions, and how variations arise despite the presentation of identical symptoms of coronary heart disease (CHD). We find that physicians show evidence of cognitive biases but also actively interpret social characteristics they deem relevant to medical treatment. In an uncertain clinical context, these diagnostic pathways expose key junctures wherein physicians are detoured to alternative diagnoses, their certainty of CHD lowered, and scientific logic makes it difficult to return to a CHD diagnosis - thereby providing a fuller picture of why some cases are counted as CHD while others are not. These results have important implications insofar as diagnostic decisions like these contribute to the compilation of epidemiologic base rates, and are therefore used as part of Bayesian decision making to determine the probability of CHD in subsequent patients. This work resonates with social constructivist concerns regarding the ways disease categories are established and maintained, and potential sources of bias in official rates detected.

How are patient characteristics relevant for physicians' clinical decision making in diabetes? An analysis of qualitative results from a cross-national factorial experiment.

Variations in medical practice have been widely documented and are a linchpin in explanations of health disparities. Evidence shows that clinical decision making varies according to patient, provider and health system characteristics. However, less is known about the processes underlying these aggregate associations and how physicians interpret various patient attributes. Verbal protocol analysis (otherwise known as 'think-aloud') techniques were used to analyze open-ended data from 244 physicians to examine which patient characteristics physicians identify as relevant for their decision making. Data are from a vignette-based factorial experiment measuring the effects of: (a) patient attributes (age, gender, race and socioeconomic status); (b) physician characteristics (gender and years of clinical experience); and (c) features of the healthcare system in two countries (USA, United Kingdom) on clinical decision making for diabetes. We find that physicians used patients' demographic characteristics only as a starting point in their assessments, and proceeded to make detailed assessments about cognitive ability, motivation, social support and other factors they consider predictive of adherence with medical recommendations and therefore relevant to treatment decisions. These non-medical characteristics of patients were mentioned with much greater consistency than traditional biophysiologic markers of risk such as race, gender, and age. Types of explanations identified varied somewhat according to patient characteristics and to the country in which the interview took place. Results show that basic demographic characteristics are inadequate to the task of capturing information physicians draw from doctor-patient encounters, and that in order to fully understand differential clinical decision making there is a need to move beyond documentation of aggregate associations and further explore the mental and social processes at work.

Ambiguities of chronic illness management and challenges to the medical error paradigm.

In recent decades, an interdisciplinary quality assurance (QA) movement has emerged in health care studies, which has included increased attention to medical errors. Implicit in this QA effort is a conflict between (1) external agents encouraging the medical profession to adopt strategies for reducing errors and (2) sociological characteristics of medical practice that systematically inhibit the uptake of these strategies. Using interviews with providers and observations in two diabetes clinics in a large Midwestern city in the USA, we examine how providers understand error in their work, as well as how they think about failures in care and efforts to standardize and impose guidelines in care. We find that the prototypical vocabularies of medical error and QA, which have been largely oriented to acute illness care, are systematically mismatched to ambiguities introduced by chronic illness. These ambiguities create problems for the definition of medical errors, the collection of relevant information, the determination of long-term treatment goals, and the application of standardization efforts. Considered together, these mismatches imply diminishing returns for health policy efforts focused on reducing medical error as part of a larger QA agenda.

Using focus groups to improve the validity of cross-national survey research: a study of physician decision making.

In this article, the authors demonstrate how qualitative methods can form a foundation for quantitative research by improving instrument validity, informing the data collection process, and improving cost-effectiveness in a study of physician decision making. To test terminology, applicability, and comprehension of a quantitative questionnaire for doctors in the United States and United Kingdom, each country's researchers conducted physician focus groups with questions organized around the experiment, including (a) validity of video vignettes of actor "patients," (b) population accessibility, (c) level of remuneration, (d) appropriate endorsement figure, and (e) question comprehension. Focus group data collected during instrument development and fieldwork planning streamlined processes and achieved cost efficiencies and effectiveness for the overall study. Beyond simply adding a post hoc qualitative component to an already free-standing quantitative methodology, focus groups were used in the study formulation, where the qualitative methodology was integrated into the process of developing a valid survey instrument.

Patient and provider assessments of adherence and the sources of disparities: evidence from diabetes care.

OBJECTIVE: To (1) compare diabetes patients' self-assessments of adherence with their providers' assessments; (2) determine whether there are systematic differences between the two for certain types of patients; and (3) consider how the cognitive processing that providers use to assess adherence might explain these differences. DATA SOURCES/STUDY SETTING: Primary survey data were collected in 1998 from 156 patient provider pairs in two subspecialty endocrinology clinics in a large Midwestern city. STUDY DESIGN: Data were collected in a cross-sectional survey study design. Providers were surveyed immediately after seeing each diabetes patient, and patients were surveyed via telephone within 1 week of clinic visits. DATA COLLECTION/EXTRACTION METHODS: Bivariate descriptive results and multivariate regression analyses are used to examine how patient characteristics relate to four measures of overall adherence assessments: (1) patients' self-assessments; (2) providers' assessments of patient adherence; (3) differences between those assessments; and (4) absolute values of those differences. PRINCIPAL FINDINGS: Patient self-assessments are almost entirely independent of observable characteristics such as sex, race, and age. Provider assessments vary with observable characteristics such as patient race and age but not with less readily observable factors such as education and income. For black patients, we observe that relative to white patients, providers' assessments are significantly farther away from-although not systematically farther above or below-patients' self-assessments. CONCLUSIONS: Providers appear to rely on observable cues, particularly age and race, to make inferences about an individual patient's adherence. These findings point to a need for further research of various types of provider cognitive processing, particularly in terms of distinguishing between prejudice and uncertainty. If disparities in assessment stem more from information and communication problems than from provider prejudice, policy interventions should facilitate providers' systematic acquisition and processing of information, particularly for some types of patients.

Physician styles of patient management as a potential source of disparities: cluster analysis from a factorial experiment.

OBJECTIVE: To identify styles of physician decision making (as opposed to singular clinical actions) and to analyze their association with variations in the management of a vignette presentation of coronary heart disease (CHD). DATA SOURCE: Primary data were collected from primary care physicians in North and South Carolina. STUDY DESIGN: In a balanced factorial experimental design, primary care physicians viewed one of 16 (2(4)) video vignette presentations of CHD and provided detailed information about how they would manage the case. DATA COLLECTION METHOD: 256 MD primary care physicians were interviewed face-to-face in North and South Carolina. PRINCIPAL FINDINGS: We identify three clusters depicting unique styles of CHD management that are robust to controls for physician (gender and level of experience) and patient characteristics (age, gender, socioeconomic status, and race) as well as key organizational features of physicians' work settings. Physicians in Cluster 1 "Cardiac" (N = 92) were more likely to focus on cardiac issues compared with their counterparts; physicians in Cluster 2 "Talkers" (N = 93) were more likely to give advice and take additional medical history; whereas physicians in Cluster 3 "Minimalists" (N = 71) were less likely than their counterparts to take action on any of the types of management behavior. CONCLUSIONS: Variations in styles of decision making, which encompass multiple outcome variables and extend beyond individual-level demographic predictors, may add to our understanding of disparities in health quality and outcomes.

Gendered uncertainty and variation in physicians' decisions for coronary heart disease: the double-edged sword of "atypical symptoms".

Nonmedical factors and diagnostic certainty contribute to variation in clinical decision making, but the process by which this occurs remains unclear. We examine how physicians' interpretations of patient sex-gender affect diagnostic certainty and, in turn, decision making for coronary heart disease. Data are from a factorial experiment of 256 physicians who viewed 1 of 16 video vignettes with different patient-actors presenting the same symptoms of coronary heart disease. Physician participants completed a structured interview and provided a narrative about their decision-making processes. Quantitative analysis showed that diagnostic uncertainty reduces the likelihood that physicians will order tests and medications appropriate for an urgent cardiac condition in particular. Qualitative analysis revealed that a subset of physicians applied knowledge that women have "atypical symptoms" as a generalization, which engendered uncertainty for some. Findings are discussed in relation to social-psychological processes that underlie clinical decision making and the social framing of medical knowledge.

Influences of organizational features of healthcare settings on clinical decision making: qualitative results from a cross-national factorial experiment.

A proliferating literature documents cross-national variation in medical practice and seeks to explain observed differences in terms of the presence of certain kinds of healthcare systems, economic, and cultural differences between countries. Less is known about how providers themselves understand these influences and perceive them as relevant to their clinical work. Using qualitative data from a cross-national factorial experiment in the United States and United Kingdom, we analyze 244 primary care physicians' explanations of how organizational features of their respective healthcare settings influence the treatment decisions they made for a vignette patient, including affordability of care; within-system quality deficits; and constraints due to patient behavior. While many differences are attributed to financial constraints deriving from two very differently structured healthcare systems, in other ways they are reflections of cultural and historical expectations regarding medical care, or interactions between the two. Implications, including possible challenges to the implementation of universal care in the USA, are discussed.

Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis.

PURPOSE: Premature closure has been identified as the single most common cause of diagnostic error. This factorial experiment explored which variables exert an unconfounded influence on physicians' diagnostic flexibility (changing their minds about the most likely diagnosis during a clinical case presentation). METHOD: In 2007-2008, 256 practicing physicians viewed a clinically authentic vignette simulating a patient presenting with possible coronary heart disease (CHD) and provided their initial impression midway through the case. At the end, they answered questions about the case, indicated how they would continue their clinical investigation, and made a final diagnosis. The authors used general linear models to determine which patient factors (age, gender, socioeconomic status, race), physician factors (gender, age/experience), and process variables were related to the likelihood of physicians' changing their minds about the most likely diagnosis. RESULTS: Physicians who had less experience, those who named a non-CHD diagnosis as their initial impression, and those who did not ask for information about the patient's prior cardiac disease history were the most likely to change their minds. Participants' certainty in their initial diagnosis, the additional information desired, the diagnostic hypotheses generated, and the follow-up intended were not related to the likelihood of change in diagnostic hypotheses. CONCLUSIONS: Although efforts encouraging physicians to avoid cognitive biases and to reason in a more analytic manner may yield some benefit, this study suggests that experience is a more important determinant of diagnostic flexibility than is the consideration of additional diagnoses or the amount of additional information collected.

What do physicians gain (and lose) with experience? Qualitative results from a cross-national study of diabetes.

An empirical puzzle has emerged over the last several decades of research on variation in clinical decision making involving mixed effects of physician experience. There is some evidence that physicians with greater experience may provide poorer quality care than their less experienced counterparts, as captured by various quality assurance measures. Physician experience is traditionally narrowly defined as years in practice or age, and there is a need for investigation into precisely what happens to physicians as they gain experience, including the reasoning and clinical skills acquired over time and the ways in which physicians consciously implement those skills into their work. In this study, we are concerned with 1) how physicians conceptualize and describe the meaning of their clinical experience, and 2) how they use their experience in clinical practice. To address these questions, we analyzed qualitative data drawn from in-depth interviews with physicians from the United States, United Kingdom, and Germany as a part of a larger factorial experiment of medical decision making for diabetes. Our results show that common measures of physician experience do not fully capture the skills physicians acquire over time or how they implement those skills in their clinical work. We found that what physicians actually gain over time is complex social, behavioral and intuitive wisdom as well as the ability to compare the present day patient against similar past patients. These active cognitive reasoning processes are essential components of a forward-looking research agenda in the area of physician experience and decision making. Guideline-based outcome measures, accompanied by underdeveloped age- and years-based definitions of experience, may prematurely conclude that more experienced physicians are providing deficient care while overlooking the ways in which they are providing more and better care than their less experienced counterparts.

Do physicians attend to base rates? Prevalence data and statistical discrimination in the diagnosis of coronary heart disease.

OBJECTIVE: To examine whether physicians attend to gender prevalence data in diagnostic decision making for coronary heart disease (CHD) and to test the hypothesis that previously reported gender differences in CHD diagnostic certainty are due to discrimination arising from reliance on prevalence data ("statistical discrimination"). DATA SOURCES: A vignette-based experiment of 256 randomly sampled primary care physicians conducted from 2006 to 2007. STUDY DESIGN: Factorial experiment. Physicians observed patient presentations of cardinal CHD symptoms, standardized across design factors (gender, race, age, socioeconomic status). DATA COLLECTION: Structured interview. PRINCIPAL FINDINGS: Most physicians perceived the U.S. population CHD prevalence as higher in men (48.4 percent) or similar by gender (44.9 percent). For the observed patient, 52 percent did not change their CHD diagnostic certainty based on patient gender. Forty-eight percent of physicians were inconsistent in their population-level and individual-level CHD assessments. Physicians' assessments of CHD prevalence did not attenuate the observed gender effect in diagnostic certainty for the individual patient. CONCLUSIONS: Given an adequate presentation of CHD symptoms, physicians may deviate from their prevalence data during diagnostic decision making. Physicians' priors on CHD prevalence did not explain the gender effect in CHD certainty. Future research should examine personal stereotypes as an explanation for gender differences.

The decision to intensify therapy in patients with type 2 diabetes: results from an experiment using a clinical case vignette.

PURPOSE: Lack of medication intensification is a widely recognized but poorly understood barrier to effective diabetes care. We used a video case vignette to assess whether patient or physician demographic variables influence the decision to intensify therapy. METHODS: One hundred ninety-two US primary care physicians each viewed one case vignette of an actor portraying a patient who had type 2 diabetes and borderline indications for medication intensification. Case vignettes were clinically identical and differed only by patient age (35 or 65 years old); sex; race/ethnicity (white, Hispanic, or black); and socioeconomic status (occupation of lawyer or janitor). After viewing the vignette and indicating their management plans, physicians were also asked to discuss the challenges related to managing such a patient. RESULTS: Just over half (53%) of physicians indicated that they would recommend a medication prescription for the vignette patient. Demographic characteristics (of the patient, physician, or practice) did not significantly influence this decision (P > .1 for all comparisons). Compared with physicians who did not recommend a diabetic-related prescription, physicians recommending therapy more often identified patient medication costs (74% vs 43% of physicians who would not increase therapy); medication adherence (63% vs 49%); and subsequent complications (34% vs 22%) as important clinical issues in managing diabetes. Physicians not intensifying therapy more often indicated that they needed more clinical information (16% vs 9%). CONCLUSIONS: Using an experimental design we found that differences in the decision to intensify therapy were not significantly explained by patient, physician, or practice demographic variables. Physicians who intensified therapy were more likely to consider issues such as medication costs, patient adherence, and downstream complications.

Physician clinical information technology and health care disparities.

The authors develop a conceptual framework regarding how information technology (IT) can alter within-physician disparities, and they empirically test some of its implications in the context of coronary heart disease. Using a random experiment on 256 primary care physicians, the authors analyze the relationships between three IT functions (feedback and two types of clinical decision support) and five process-of-care measures. Endogeneity is addressed by eliminating unobserved patient characteristics with vignettes and by proxying for omitted physician characteristics. The results indicate that IT has no effects on physicians' diagnostic certainty and treatment of vignette patients overall. The authors find that treatment and certainty differ by patient age, gender, and race. Consistent with the framework, IT's effects on these disparities are complex. Feedback eliminated the gender disparities, but the relationships differed for other IT functions and process measures. Current policies to reduce disparities and increase IT adoption may be in discord.

Diagnostic certainty as a source of medical practice variation in coronary heart disease: results from a cross-national experiment of clinical decision making.

The authors examined physician diagnostic certainty as one reason for cross-national medical practice variation. Data are from a factorial experiment conducted in the United States, the United Kingdom, and Germany, estimating 384 generalist physicians' diagnostic and treatment decisions for videotaped vignettes of actor patients depicting a presentation consistent with coronary heart disease (CHD). Despite identical vignette presentations, the authors observed significant differences across health care systems, with US physicians being the most certain and German physicians the least certain (P < 0.0001). Physicians were least certain of a CHD diagnoses when patients were younger and female (P < 0.0086), and there was additional variation by health care system (as represented by country) depending on patient age (P < 0.0100) and race (P < 0.0021). Certainty was positively correlated with several clinical actions, including test ordering, prescriptions, referrals to specialists, and time to follow-up.

An examination of the association of abuse (physical, sexual, or emotional) and female sexual dysfunction: results from the Boston Area Community Health Survey.

OBJECTIVE: To examine associations between abuse (physical, sexual, and emotional) in childhood and adolescence/adulthood and sexual activity and dysfunction in women. DESIGN: We analyzed data from the Boston Area Community Health Survey, a community-based epidemiologic study of urologic and sexual symptoms and risk factors in a racially and ethnically diverse random sample of women aged 30-79 years (N = 3,205 women). SETTING: Boston area community. PATIENT(S): Participants were community residents. INTERVENTION(S): Data were observational; no interventions were made. MAIN OUTCOME MEASURE(S): Sexual activity and dysfunction rates were assessed by means of a validated questionnaire (the Female Sexual Function Index). RESULT(S): Abuse history was not significantly associated with likelihood of sexual activity. Among those who were sexually active with a partner, a history of each of three types of abuse approximately doubles the odds of female sexual dysfunction. Specifically, childhood emotional (odds ratio [OR] 2.13, 95% confidence interval [CI] 1.28-3.56), adult sexual (OR 1.94, 95% CI 1.23-3.08), and adult emotional abuse (OR 1.86, 95% CI 1.15-3.01) were all significantly and positively associated with sexual dysfunction after adjusting for covariates (including depression). Analyses of the six female sexual dysfunction domains showed that the relationships were strongest for pain and satisfaction. CONCLUSION(S): These findings extend those from previous studies by identifying an association between female sexual dysfunction and multiple types of abuse, even after adjusting for depression.