Influence of patient race on physician prescribing decisions: a randomized on-line experiment

Abstract

Background: Prior research reports black patients have lower medication use for hypercholesterolemia, hypertension, and diabetes.

Objective: To assess whether patient race influences physicians' prescribing.

Design: Web-based survey including three clinical vignettes (hypercholesterolemia, hypertension, diabetes), with patient race (black, white) randomized across vignettes.

Subjects: A total of 716 respondents from 5,141 eligible sampled primary care physicians (14% response rate).

Interventions: None

Measurements: Medication recommendation (any medication vs none, on-patent branded vs generic, and therapeutic class) and physicians' treatment adherence forecast (10-point Likert scale, 1-definitely not adhere, 10-definitely adhere).

Results: Respondents randomized to view black patients (n = 371) and white patients (n = 345) recommend any medications at comparable rates for hypercholesterolemia (100.0% white vs 99.5% black, P = 0.50), hypertension (99.7% white vs 99.5% black, P = 1.00), and diabetes (99.7% white vs 99.7% black, P = 1.00). Patient race influenced medication class chosen in the hypertension vignette; respondents randomized to view black patients recommended calcium channel blockers more often (20.8% black vs 3.2% white) and angiotensin-converting enzyme inhibitors less often (47.4% black vs 62.6% white) (P < 0.001). Patient race did not influence medication class for hypercholesterolemia or diabetes. Respondents randomized to view black patients reported lower forecasted patient adherence for hypertension (P < 0.001, mean: 7.3 black vs 7.7 white) and diabetes (P = 0.05 mean: 7.4 black vs 7.6 white), but race had no meaningful influence on forecasted adherence for hypercholesterolemia (P = 0.15, mean: 7.2 black vs 7.3 white).

Conclusion: Racial differences in outpatient prescribing patterns for hypertension, hypercholesterolemia, and diabetes are likely attributable to factors other than prescribing decisions based on patient race.

Figure 1

Patient actor photos. Photos of patient actors utilized in the study. Respondents were randomized to view black patient actors (images A, B, and C) or white patient actors (images D, E, and F) for all three vignettes. Used, with permission, from Schulman KA, NEJM 1999.

Figure 2

Sample vignette screen. Screen displaying vignette, treatment choices, and patient actor.