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

Study Design and Participants

We conducted a qualitative study, which uses methods best suited for eliciting broad themes and patterns when no previously described theoretical framework exists.^27,28 We undertook 18 semistructured interviews with primary care physicians in Connecticut to elicit their perceptions, beliefs, and experiences in caring for patients of low SES. We chose this method of research in the belief that physician participants were most likely to respond candidly in the context of one-on-one discussion with a physician interviewer.

To identify a sample of physicians who care for patients of low SES, the population of primary care physicians who provide care for Medicaid patients in the state was used as a sampling frame. First, physicians in this population were randomly identified and contacted for an interview. Fourteen physicians were initially contacted and 11 agreed to an interview. Second, physicians were purposefully selected from the Medicaid pool to maximize variation on those characteristics we believed might shape physicians’ perceptions of caring for patients of low SES: race and ethnicity, practice type (private practice, community health center, academic practice), and practice setting (rural, urban, suburban). Four additional physicians were contacted, and all agreed to be interviewed. Last, we used a snowball technique to identify minority physicians and those caring for veterans who we believed were underrepresented in our emerging sample.²⁷ Three physicians were identified using this approach, and all agreed to participate.

We provided written information about the project to participants. Informed consent was completed verbally to avoid producing written materials that could be used to identify participants. Additionally, any potentially identifying information given during interviews was removed from transcripts. This project was approved by the Institutional Review Board at Yale University.

Data Collection

All interviews were conducted by a physician investigator—a family physician (S.M.B.) or an internist (J.S.R.). The interviews were semistructured, using an interview guide composed of open-ended questions and additional prompts. The interview guide was pilot tested on 2 physicians from neighboring states before starting the study. Interviews began with a broad question asking how physicians thought patients’ SES influences patient care.²⁹ Physicians were further prompted to give specific examples of changes in patient management and encouraged to think about a range of ways that SES influences care. We did not define socioeconomic status because we wanted to gain insight into physicians’ own conception of SES and which factors associated with SES they believed influenced patient care management decisions. All participants completed a brief written form describing their demographic background, practice setting, and years of clinical experience. Interviews were recorded and professionally transcribed by an independent transcriptionist.

Data Analysis

We used line-by-line open coding to develop the coding structure.^27,28 Three investigators (S.M.B., J.S.R., E.H.B.) independently coded each transcript, tagging sections of data with appropriate codes. After every 2 to 3 interviews, the researchers met to compare coding and resolved differences with negotiated consensus. As new concepts emerged, the code structure was refined and the interview guide was modified to reflect emerging themes, as is common in qualitative research.^27,30,31 Periodically a member of the research team (S.M.B.) reread previously coded transcripts and recoded using the enhanced code structure to ensure earlier data were fully analyzed. In addition, the research team reviewed data within codes several times to ensure consistency in their use and full understanding of their scope and meaning. This process is consistent with the constant comparative method²⁷ or editing analysis.³² From this process, recurrent themes emerged that characterized the experiences of the participants. Additional interviews were conducted until no new concepts emerged with successive interviews, a process known as thematic saturation.³² We selected verbatim quotations from the transcribed data to illustrate the recurrent themes using Atlasti software (Scientific Software Development, GmbH Berlin, version 5.0.67). Quotes were edited to improve readability. A physician identification number is included after each quotation. Participating physicians were contacted after the data analysis was complete and given an opportunity to comment on the final themes that emerged from interviews. No substantive changes were made during this process.

Conflicting Views: SES and Clinical Management

Some physicians indicated that patient SES substantially influenced clinical management and that tailoring care to account for SES was central to providing high-quality care. As one said, “I need to understand where they are and how to fit their mold to help them come up with the best possible outcome [physician 4].” Most physicians’ statements, however, divulged more conflicted views about the influence of patient SES on clinical management. A common tendency was for physicians to report their belief that the “standard of practice should not be [influenced] by low socioeconomic status [physician 2].” Nevertheless, during the course of the interviews, nearly all physicians recounted circumstances in which the patient’s SES did affect their clinical management decisions. Even physicians who initially asserted that all patients in their practice received identical care later described differences based on patient SES. For instance, 1 physician said at the beginning of an interview, “I see the full gamut. I see the CEOs and then I see the neighborhood, low-SES patients. And really, it is invisible to me. They get the exact same approach and treatment [physician 9].” Later in the same interview, however, this physician described changing prescriptions and reducing diagnostic testing because a patient had a lower SES.

The prevailing sense that SES should not but nonetheless does influence clinical management decisions was expressed by this physician:

When we see a patient, we do not really think this patient is from the poorer strata and [so we are] going to give him a different medication. But when it actually comes to the practicality of it, we have to, because he is not going to buy the medication we have prescribed [physician 8].

Clinical Management Changes Made in Patient’s Interest

Most of the changes physicians described as based on a patient’s SES were made to provide care that was more affordable, feasible, or comprehensible for a patient. To make care more affordable to patients as a result of income or insurance restrictions, for instance, physicians described using less-expensive medications, avoiding specialist referrals, trying to accomplish more in a single visit, and postponing testing. Below a physician describes treating a patient he thought had sleep apnea but who could not afford a sleep study or a visit to a sleep specialist:

So I put him on oxygen. ... Right now, he is saying that symptomatically he is feeling a little better. I still feel concerned that we are treating it half-heartedly. This is not the right treatment, but this is what we can do, and that is what we are trying to do [physician 2].

In other cases a physician’s aim was to make care more feasible given a patient’s lifestyle. Here a physician describes matching a diabetic patient’s care to the patient’s occupation and work schedule:

He was a trucker … we really had to tailor the medication. He did not have any proper time to eat, and, you know, he did not have time to come to his appointments. We have to tailor his appointments according to his travel schedule. It is not optimal, but we do the best we can [physician 8].

Additionally, to make care more comprehensible, physicians described taking more time to communicate fewer pieces of information or incorporating family members into discussions because of concerns about patients’ limited literacy. In another example a physician described changing his style of speech to mirror a patient’s in hopes of improving adherence and outcomes:

Sit with me during an interview with a 26-year-old factory worker. I don’t speak the same. I listen to him, I watch him, I pace with him. I use his lingo, there is a lot of “dude,” “buddy” kind of terminology. … Whatever I am trying to do is always trying to impact the outcomes, because that is my job [physician 11].

Clinical Management Changes and Influence on Patient Outcomes

In some cases, physicians believed that, although they provided different care for patients of low SES when compared with patients of higher SES, patient outcomes did not differ. For instance, physicians intimated that prescribing a generic rather than a name brand medication, changing communication styles, or eliminating treatments of uncertain benefit did not compromise patient outcomes generally. One physician, in fact, described what he viewed as excessive care for more affluent patients:

This patient comes in with pneumonia—patient A with good [insurance]. Here’s your Levpack … nasal inhaler, especially Advair. Here’s your guaifenesin with phenylephrine with hydroxy-blah-blah-blah. Then patient B with no insurance. Here’s your penicillin. Take deep breaths, 3 times a day, cough hard, humidify at night, steam inhalation will help you as well. So SES changes things. Patient A probably will have all the unnecessary things that I give because I play defensive. Patient B does just as well [physician 3].

In other cases, however, physicians indicated the clinical management decisions made to accommodate a patient’s low SES could compromise outcomes. One physician described patient finances as limiting medication choices and inevitably leading to worse outcomes for the patient:

I’m a believer that with chronic pain you should use longer-acting narcotics, [but] our drug of choice is just too expensive for him. … As a result, we have been forced to use less-expensive medications, and I’ve had great difficulty getting his pain under good control [physician 1].

Finally, physicians described tailoring care based on a patient’s SES as a way to mitigate the negative impact of SES on patient outcomes. The following physician describes being less aggressive with diabetes treatment as a means of enhancing outcomes for patients who “because of the combination of their lack of insurance, their understanding of the disease, and just what personal difficulties they are going through at the time” will often not show up for long periods of time. This physician contrasted his approach with that of his colleagues who were inflexible in their treatment plans, which he believed resulted in worse outcomes for patients of low SES:

I think my care is affected because I know that at times if I’m too rigid, the patients won’t come back …, [so we] try to reach an understanding with the patients, and this way perhaps there is a compromise of care, but the other side would be that the patients would just be lost [physician 18].

Strains of Caring for Patients of Low SES

In changing their clinical management decisions to account for a patient’s SES, physicians experienced tension between an ideal of maintaining a consistent standard of care for all patients and providing care that was not the standard of care but what they believed was appropriate given a patient’s SES. One way this tension was conveyed was in physicians’ concern that they may appear to be providing lower quality care to patients of low SES, even when they believed it was in a patient’s best interest:

I try to practice good medicine all the way through. But sometimes when I am limited, it would seem like it is less than good medicine. But it is still as appropriate as you can get within the limits that you have [physician 15].

For some physicians concerns about not maintaining standards of care and about worse patient outcomes were compounded by increased attention to performance measurement:

You are graded as a doctor by everybody in the world. Used to be if you were a nice person and you practiced good medicine that was enough, now you have to have data. What do you do if the patient does not follow the game plan? There are ways to try to coax the patients back in, but how much time and energy do you have at the time [physician 11]?

In addition, physicians gave many examples of having to work harder in an effort to maintain a standard of care for patients of low SES. They spoke of putting extra time into obtaining free medications or seeking colleagues to accept specialty referrals and of adding staff members to help patients of low SES navigate the health care system. Furthermore, some physicians stated that they could no longer afford to accept new Medicaid or uninsured patients and questioned the sustainability of the current health care system. As one stated:

Being able to find consultants, find people to take care of them, is very frustrating, and I think a lot of it comes down to dollars and cents. It is very frustrating because it puts a barrier right between you and the patient. And, you know, lights have to be paid for, the staff has to be paid—if you are not be able to do that, you are done. And so what do you do? It is hard [physician 10].

Finally, physicians described being burdened by fears about their level of responsibility for the influence of patient SES on health care quality and outcomes:

If a patient comes in with adequate health care [coverage] [and a blood pressure of] 190/100 mm Hg, you say, “Here, I give you some medications to make sure that your blood pressure goes down.” The patient with no money [and a blood pressure of] 190/100 mm Hg, I give him some samples, and then what? I give him a script. He does not have [the medication because of costs]. I wonder after these 30 days, after these pills, what is going to happen? Will I see him in the newspaper obituary from a stroke [physician 16]?