Quality of Communication and Trust in Patients With Serious Illness: An Exploratory Study of the Relationships of Race/Ethnicity, Socioeconomic Status, and Religiosity

Abstract

Context: Better understanding of clinicians' skill communicating with their patients and of patients' trust in clinicians is necessary to develop culturally sensitive palliative care interventions. Race/ethnicity, socioeconomic status, and religiosity have been documented as factors influencing quality of communication and trust.

Objectives: The objective of this study was to explore associations of seriously ill patients' race/ethnicity, socioeconomic status, and religiosity with patients' ratings of the quality of clinicians' communication and trust in clinicians.

Methods: An observational analysis was performed using baseline data from a multicenter cluster-randomized trial of a communication intervention. We enrolled consecutive patients with chronic, life-limiting illnesses (n = 537) cared for by primary and specialty care clinicians (n = 128) between 2014 and 2016 in outpatient clinics in Seattle, Washington. We assessed patient demographics (age, gender, race/ethnicity, education, income, and self-rated health status), Duke University Religion Index, Quality of Communication Scale, and Wake Forest Physician Trust Scale. We used probit and linear regression and path analyses to examine associations.

Results: Patients providing higher ratings of clinician communication included those belonging to racial/ethnic minority groups (P = 0.001), those with lower income (P = 0.008), and those with high religiosity/spirituality (P = 0.004). Higher trust in clinicians was associated with minority status (P = 0.018), lower education (P = 0.019), and clinician skill in communication (P < 0.001).

Conclusion: Contrary to prior studies, racial/ethnic minorities and patients with lower income rated communication higher and reported higher trust in their clinicians than white and higher income patients. More research is needed to identify and understand factors associated with quality communication and trust between seriously ill patients and clinicians to guide development of patient-centered palliative care communication interventions.

Trial registration: ClinicalTrials.gov NCT01933789.

Keywords: Quality of communication; race/ethnicity; religiosity; serious illness; trust.

Figure 1.. Path Model of the Effects of Patient Race, Education, Income, Religiosity/Spirituality on Clinicians’ Skill at End-of-Life Communication and Patients’ Overall Trust in the Clinician^a

a Model based on probit regression, estimated with weighted least squares with mean and variance adjustment (WLSMV); unstandardized coefficients with theta parameterization; positive coefficients indicate that the predictor and outcome rise and fall together, whereas negative coefficients indicate that an increase in the predictor contributes to a decrease in the outcome and vice versa; and larger coefficients indicate that a 1-unit increase in the predictor has a greater effect on the outcome than does a smaller coefficient; p-value for each structural coefficient shown as superscript next to the coefficient. X² test of model fit: X² = 18.796, 17 df, p=0.3404. Statistically significant total effect of racial/ethnic minority status on quality of communication (b=0.735, p=0.001) included a significant direct effect (b=0.602, p=0.006), with an additional indirect effect through education and income, which was substantial, but statistically non-significant (b=0.133, p=0.052). There was also a significant indirect effect of racial/ethnic minority status on the religious-beliefs indicator of the quality-of-communication construct, through religiosity (0.886, p<0.001). Statistically significant total effect of racial/ethnic minority status on trust (b=0.208, p=0.006), which was entirely indirect through education, income, and quality of communication.