Minority health-care clinics separate but unequal

A study published today in the Archives of Internal Medicine may shed new light on why minority Americans have poorer health outcomes from chronic conditions such as hypertension, heart disease and diabetes.

Researchers found that clinics serving higher proportions of these minority patients tend to have more challenging work environments and organizational characteristics.

"Unfavorable patient and physician outcomes may be attributable to disparities in work conditions at these clinics," said Anita Varkey, MD, lead author, assistant professor in the department of medicine, Loyola University Chicago Stritch School of Medicine and medical director of general medicine at Loyola Outpatient Center, Loyola University Health System. "When you have limited access to medical supplies, referral specialists, and examination rooms, coupled with a more complex patient mix, you can start to see the challenges involved with providing high quality primary care."

Few studies have examined the influence of physician workplace conditions on health care disparities. This study compared 96 primary care clinics in five regions, including Chicago. Data were collected from 388 primary care physicians and 1,701 adult patients with chronic diseases. Researchers compared 27 clinics (41.8 percent of physicians) that had at least 30 percent minority patients with 69 clinics (45.9 percent of physicians) that had less than 30 percent. The clinics with larger proportions of minority patients were four times more likely to have a chaotic work environment, and their physicians were half as likely to report job satisfaction. These physicians also had a tendency to report higher stress and intention to leave.

"All of these factors can contribute to health care disparities," said Varkey. "Challenges in workplace characteristics exacerbate time pressures already complicated by disadvantaged patients with chronic medical and psychosocial issues."

Patients in clinics with higher proportions of minorities were more frequently depressed (22.8 percent vs. 12.1 percent), more often covered by Medicaid (30.2 percent vs. 11.4 percent), and had lower health literacy (3.7 vs. 4.4, on a scale where one is lowest and five is highest). Physicians from these clinics reported that more of their patients spoke little to no English (27.1 percent vs. 3. 4 percent), had more chronic pain (24.1 percent vs. 12.9 percent), substance abuse problems (15.1 percent vs. 10.1 percent), and complex medical cases.

The authors indicated that strategies to improve patient care for these clinics should go beyond efforts to improve health care coverage and reimbursement. Interventions also should target measures to reduce physician burnout, clinic chaos and work control measures.

"While further research is needed, health care reform strategies should consider the role that work environment plays in quality of care," said Varkey.