Impact of Work Conditions and Minority Patient Populations on Quality and Errors

Introduction

Racial disparities in health care may be influenced by the sites where patients receive care. ^1-2 One study showed that black patients were more likely to attend hospitals with lower rates of evidence-based medical treatments, ² while another showed that risk-adjusted mortality after acute myocardial infarction was greater in hospitals with high proportions of black patients. ³ Health disparities research has recently focused on addressing these decrements in quality.

The Minimizing Error Maximizing Outcome (MEMO) Study found more challenging work conditions in primary care clinics that served minority patients. ⁴ Physicians practicing in these clinics had less access to specialists, clinical resources, and examination rooms. Doctors in these clinics reported more chaotic workplaces, less control, and lower job satisfaction. Based on these troubling findings, we examined data from MEMO to answer the following questions: Are there differences in quality of care or errors between clinics serving large proportions of minority patients and those serving mainly nonminority patients, and, if so, how far do work conditions explain these differences?

Method

The 2002-2005 MEMO study was a longitudinal investigation of primary care clinics in New York city; Chicago, Illinois; and rural, academic, and urban settings in Wisconsin. ⁵ Eligible participants were family practitioners or general internists with at least 4 sessions per week in ambulatory care. Up to 6 patients per physician were recruited by mail or in person. Eligibility criteria included age 18 or older; ability to read English, Spanish, or Cantonese; at least 2 outpatient visits with a study physician in the previous year; and a diagnosis of hypertension, diabetes mellitus, and/or congestive heart failure. (Heart failure patients were eventually eliminated from analysis due to systematic challenges in data collection.) Clinics serving ≥30% minority populations based on manager data were deemed minority-serving clinics (MSCs). This threshold resembles the 2005 U.S. proportion of Blacks plus Hispanics. ⁶

A physician survey queried satisfaction, stress, burnout, work control, referral access, office pace (calm to chaotic), access to clinical resources, and likelihood to leave within 2 years. Managers reported on examination room availability. Patient records were audited retrospectively over 18 months for errors, quality, diabetes control, and hypertension control based on national guidelines. Error points were assigned for missing processes of care, including depression screening, diet/exercise advice, tobacco use documentation, and cancer screening. Quality points were assigned for control of diabetes (Hemoglobin A1c ≤7.5%) and hypertension (blood pressure <140/90 or <130/85 for diabetic patients) for ≥50% of recorded measurements. ⁷

Two-level hierarchical patient–physician structural models tested the following: (1) associations between MSC status and errors, quality, diabetes control, and hypertension control and (2) the mediating effects of time pressure, chaos, work control, resources, referral access, and examination rooms. Models were adjusted for patient and physician demographics. Figure 1 illustrates the analysis’ conceptual basis.

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Figure 1.

Conceptual model.

Results

The MEMO recruited 119 clinics, 422 physicians (54% of those approached), and 1795 patients. Seventy-three clinics had complete data (287 physicians and 1204 patients). Among physicians, 63% were general internists and 48% were females. Among patients, 65% were females, 54% had diabetes, 90% had hypertension, and 44% had both. Of the 73 clinics, 36% were MSCs. Parameter estimates for the models are available from the authors upon request.

Discussion

Our previous work has uncovered challenging work conditions in MSCs. ⁴ In this study of 287 primary care physicians and 1204 patients, we found greater overall errors and poorer diabetes control in clinics serving larger proportions of minority patients. The study provides evidence that one of these conditions, access to clinical resources, explains in large part the 5% difference in overall errors between MSCs and NMSCs and partially accounts for better diabetes control in NMSCs. Our data also provide evidence that examination room availability and access to specialists are associated with improved control of blood pressure and higher overall quality.

One key finding from this study is the importance of sufficient examination rooms. Fewer examination rooms were found per provider per session in MSCs. Diminished room availability was linked to lower quality of care. We thus encourage all clinics, especially those serving minority patients, to allow sufficient space for conducting clinical examinations and providing high-quality care.

Limitations of our study include self-reported physician data and patients residing in few geographical regions. While data are from 2002 to 2005, they remain pertinent due to the strong study design and likely stability of relationships between predictor variables and clinical outcomes. The MEMO’s many strengths (including a diverse patient population, a large number of clinics, and objective outcome data) support the importance of the findings.