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Influence of Patients’ Socioeconomic Status on Clinical Management Decisions: A Qualitative Study

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

CORRESPONDING AUTHOR: Susannah M. Bernheim, MD, MHS, Yale University School of Medicine, 333 Cedar St, PO Box 208025, New Haven, CT 208088, susannah.bernheim{at}yale.edu

PURPOSE Little is known about how patients’ socioeconomic status (SES) influences 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 influences care.

METHODS The study consisted of in-depth semistructured interviews with primary care physicians in Connecticut. Investigators coded interviews line by line and refined 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 conflicting 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 influenced patient outcomes, and (4) physicians faced personal and financial 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.

Key Words: Socioeconomic factors • healthcare disparities • quality of healthcare • qualitative research

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