Race, income, and education: associations with patient and family ratings of end-of-life care and communication provided by physicians-in-training

Abstract

Background: Minority race and lower socioeconomic status are associated with poorer patient ratings of health care quality and provider communication.

Objective: To examine the association of race/ethnicity or socioeconomic status with patients' and families' ratings of end-of-life care and communication about end-of-life care provided by physicians-in-training.

Methods: As a component of a randomized trial evaluating a program designed to improve clinician communication about end-of-life care, patients and patients' families completed preintervention survey data regarding care and communication provided by internal medicine residents and medical subspecialty fellows. We examined associations between patient and family race or socioeconomic status and ratings they gave trainees on two questionnaires: the Quality of End-of-Life Care (QEOLC) and Quality of Communication (QOC).

Results: Patients from racial/ethnic minority groups, patients with lower income, and patients with lower educational attainment gave trainees higher ratings on the end-of-life care subscale of the QOC (QOCeol). In path models, patient educational attainment and income had a direct effect on outcomes, while race/ethnicity did not. Lower family educational attainment was also associated with higher trainee ratings on the QOCeol, while family non-white race was associated with lower trainee ratings on the QEOLC and general subscale of the QOC.

Conclusions: Patient race is associated with perceptions of the quality of communication about end-of-life care provided by physicians-in-training, but the association was opposite to our hypothesis and appears to be mediated by socioeconomic status. Family member predictors of these perceptions differ from those observed for patients. Further investigation of these associations may guide interventions to improve care delivered to patients and families.

FIG. 1.

Path model of associations between patient factors and the Quality of Communication (QOC) Questionnaire's end-of-life communication (QOCeol) ratings.

FIG. 2.

Path model of associations between patient predictors and the number of Quality of Communication Questionnaire's (QOC) end-of-life communication (QOCeol) items that were not performed.