Querying Patients About Race and Ethnicity

www.CenterForUrbanHealth.org

MN Health Services Research Conference. 06MAR07

Querying Patients About Race and Ethnicity

at Hennepin County Medical Center

Yiscah Bracha,M.S.Research Director, CUH


:N e e d f o r p a t ie n t r a c e d a t a

• For providers to identify and eliminate instances of disparities in delivery of medical care

• For researchers to monitor disparities: Comparisons across geographic region Trends over time Associations with other factors


. :N a t l R e s e a r c h S h o w s

• Not all providers obtain patient race data• Among providers that do, querying is

uncomfortable Patients feel privacy invaded, suspicious

about how data will be used; Registrars reluctant to query them

• Inconsistency in questions asked & response categories used


: G o a l

• Establish method to query patients about: Race Ethnicity Other personal demographic characteristics

• Qualities of method: Respectful towards patients Quick and easy to administer Captures clinical important differences Enables reporting using OMB classification


: S e t t in g H e n n e p in C o u n t y M e d ic a l C e n t e r

• Publicly-owned, urban, safety net in downtown Minneapolis, MN

• Level one trauma center• Hospital: 19,000 patients per year• Clinics: 168,000 outpatients per year

On-campus primary care (3 clinics) Community-based primary care (3 clinics) 20+ on-campus specialty clinics


H e n n e p in C o u n t y M e d ic a l ( ):C e n t e r H C MC

• Multi-racial ~30% American-born Caucasian ~20% African-American ~12% 1st or 2nd generation African immigrant ~21% Hispanic ~13% Asian, Native American, European immigrant

• Multi-ethnic African-American vs. African-born European-American vs. European-born Hmong vs. Vietnamese vs. Indian Mexican vs. Ecuadoran vs. Columbian

• Multi-lingual Interpreter services in > 60 languages Spanish, Somali, Hmong most common non-English languages


:Th e Q u e s t io n

• What is the best way to query ptts about race/ethnicity to satisfy following needs: Speed during encounter Patient feels they’ve truly “identified”

themselves Clinicians & planners get fine distinctions Everyone can report using OMB categories


?Wh o n e e d s w h a t

Registries * Clinical Researchers * Public Health Departments•Fixed response choices•OMB reporting format

CliniciansPlanning & Marketing

•Fine distinctions

Interviewer/Patient Pair

•Patient-perception•Simple•Short


H C MC E x p e r im e n t

• Conducted in January and February 2006• Used 4 HCMC registrars/schedulers (2 staffed

Spanish telephone line)• Four methods tested

Each tested by 2+ interviewers, on 2+ days Each tested until > 30 interviews took place

• Outcomes of interest Registrar feedback on ease of administration Percent questions refused & incomplete interviews Average administration time


H C MC E x p e r im e n t a lM e t h o d s

• Proposed data entry screen mimicked with Microsoft Access

• Registrar switched to Access screen at appropriate time during live patient interview

• Access recorded: Responses provided (including refusals) Time to administer entire set of questions


F o u r M e t h o d s Tr ie d

Marital statusRace or ethnicity

Question

Religious preferenceRace or ethnicity

Question

Language(s)Birthplace


F o u r m e t h o d s

1. Race? (OMB list +

White HispanicBlack Hispanic)

2. Ethnicity? (Open-ended)

1. Race? (OMB list + Hispanic)



2. Race? (OMB list)

1. Hispanic? (y/n)

2. Race? (OMB list)


Method 4Method 3Method 2Method 1


Q u a lit a t iv e R e s u lt s

• Asking Hispanic ethnicity first doesn’t work Next Q about race confuses patients Too many questions if query about birthplace as well

• Asking general ethnicity first doesn’t work Too many choices “What’s the difference between ‘race’ and ‘ethnicity’”?

• Asking race first: Works for U.S. born Works for Hispanic if responses include Hispanic Doesn’t work for foreign-born non-Hispanic, but can

overcome w.ethnicity Q follow-up


Q u a n t it a t iv e R e s u lt s

2.60.03.621.1No answer to race Q (%)

1.21.00.91.1Avg Time (mins)

92.394.9100.085.5Answered ethnicity Q (%)

92.3100.087.578.9Chose available response to race Q (%)

39595676Interviews (n)

FourThreeTwoOne

MethodOutcomes of Interest


P r e f e r r e d M e t h o d t o A s k:Q s

• What is your race? White Black or African

American Hispanic Asian Native American Other

• What is your ethnicity? Over 60 possible

choices suggested by Nationality Religion Race Language


- :O n g o in g is s u e s a t H C MC

• Technology: Cannot program EHR screen in preferred way Low “fix” priority given new EHR launch

• Registrar discomfort: Regular staff still uncomfortable querying,

especially in person Inadequate training; no time to train

• Inconsistent with OMB standard But OMB standard known to generate

incomplete race responses for Hispanics


:F u t u r e d ir e c t io n s a t H C MC

• After launch of EHR settles down: Work w/vendor to overcome technical glitches Improve training for registration staff Monitor question completion rates Conduct addl experiment to test comfort with

alternative questions


Im p lic a t io n s o f H C MC:r e s u lt s

• Conflict: Providers need:

Local detail not available in national categories Relief from administrative burden (e.g., difficult to

“roll up” detailed categories) Way to overcome patient resistance

Researchers want: Consistency across providers & localities (inimical

to local detail) Rigor in data collection methods (imposes

administrative burden on providers)


P o s s ib le r e s o lu t io n o f:c o n f lic t

• Same question order, slightly different text: Q1: “What race do most people think you

are?”Choices: Standard OMB list plus Hispanic Q2: “What race or ethnicity do you consider

yourself?”Choices: Locally determined by population(s)

provider serves


P o s s ib le a d v a n t a g e s t o:a lt e r n a t iv e

• Questions not as intrusive, thus may lessen discomfort

• Answers offer ability to distinguish between disparities due to: How patient is perceived by medical staff; Culturally-influenced patient behaviors &

beliefs• Researchers get standardization; local

providers get detail.


Extra slides: Office of Management & Budget

Statistical Directive 15 (OMB Standard)


:O MB f e d e r a l s t a n d a r d

• Established in 1997, after years of research & debate

• Mandatory for all federal data systems Not mandatory for state or private data

systems In absence of alternative standard, some

states & private entities have adopted it Some strongly advocate it be made

mandatory for all


F e a t u r e s o f O M B S t a n d a r d

• Two questions: Hispanic origin? (y/n) Race

White Black or African American Asian Pacific Islander Native American or Alaskan native Other

• Multiple responses to race question permitted


U n iv e r s a l a d o p t io n o f O M B?s t a n d a r d

• Heavily influenced by “identity” politics due to use in US Census

• Causes confusion, discomfort during administrative workflow

• Known to generate non-answers to race question by Hispanics (research conducted by Census Bureau)

• Some IT systems cannot handle 2 questions, or multiple responses


Extra slides: Issues to consider in

question administration:


?Wh o w ill a s k q u e s t io n s

• Registrar (when ptt calls for appointment) vs. clinician (when rooming patient): Advantages of registrar:

Can propagate universally throughout system Epic already includes race question on registration screen BUT:

• Lots of administrative detail to capture at that time• Registrars not accustomed to asking personal questions• Patient concern that answer will affect care

Advantages of clinician: Flows with usual questions that clinicians ask Patient already getting care; BUT:

• Difficult for clinician to find the proper screen• Difficult to propagate universally


, If r e g is t r a r a s k s w h e n :d u r in g in t e r v ie w

• Beginning vs. End: Advantages of beginning:

Q already programmed in that part of the screen Comes before Qs about payment source:

Advantages of End: Registrar has had time to establish rapport

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Querying Patients About Race and Ethnicity

Health & Medicine