Correspondence
Racial Differences in the Use of Drug Therapy for HIV Disease
N Engl J Med 1994; 331:333-334August 4, 1994
- Article
To the Editor:
Moore et al. (March 17 issue)1 present data suggesting that among patients seeking treatment at their Baltimore HIV clinic, blacks were less likely than whites to have received previous antiretroviral therapy or prophylaxis against Pneumocystis carinii pneumonia (PCP). Although data were obtained from patients' reports and “accompanying medical records when available,” Moore and colleagues do not report the degree to which data from patients' reports were validated by reviews of medical records.
As part of an ongoing interview project sponsored by the Centers for Disease Control and Prevention,2 we have collected similar data on medical care in Los Angeles County since September 1989 among persons with AIDS whose cases were reported to the local health department. A recent analysis of these data revealed substantial discordance between the reports of patients who said that they had not received medical treatments and the information in their medical records3. On the basis of interviews with 591 patients, blacks and foreign-born Latinos appeared more likely (P<0.05) than whites and U.S.-born Latinos to have received no antiretroviral therapy (8 percent and 4 percent, respectively) or PCP prophylaxis (13 percent and 3 percent, respectively) and to have had no CD4+ T-lymphocyte count determined (10 percent and 2 percent, respectively). However, among the 34 persons who answered “no” to one or more of the three questions about medical care, 23 (68 percent) had conflicting evidence in their medical records. Furthermore, this apparent misclassification (i.e., the patients reported not receiving medical care, although their medical records indicated that they had received such care) occurred more often among blacks and foreign-born Latinos than among whites and U.S.-born Latinos (79 percent vs. 40 percent, P = 0.04), suggesting that the results of the analysis of the data from interviews were biased and potentially misleading.
Discrepancies in patients' reports of previous medical care may reflect poor communication between the health care provider and the patient or between the interviewer and the patient. Many patients may not know the names of the medications they take or the reasons the medications were prescribed. In addition, problems with recall and voluntary withholding of information must be considered when assessing data based on reports by patients. These potential limitations of information reported by patients highlight the importance of validating such information by reviewing medical records whenever possible, particularly when clinical or policy decisions are at stake. We urge cautious interpretation of results in the absence of such validation.
3 ReferencesPaul A. Simon, M.D., M.P.H.
Centers for Disease Control and Prevention, Atlanta, GA 30333Frank J. Sorvillo, Ph.D.
Richard K. Lapin, M.P.H.
Los Angeles County Department of Health Services, Los Angeles, CA 900051
Moore RD ,Stanton D ,Gopalan R ,Chaisson RE . Racial differences in the use of drug therapy for HIV disease in an urban community. N Engl J Med 1994;330:763-768
Full Text | Web of Science | Medline2
Diaz T ,Chu SY ,Frederick M , et al. Sociodemographics and HIV risk behaviors of bisexual men with AIDS: results from a multistate interview project. AIDS 1993;7:1227-1232
CrossRef | Web of Science | Medline3
Lapin R, Sorvillo F, Kerndt P, et al. An evaluation of apparent disparities in medical care quality among minority AIDS patients in Los Angeles. Presented at the Ninth International Conference on AIDS, Berlin, Germany, June 6-11, 1993.
Author/Editor Response
The authors reply:
To the Editor: Whether the results of the study by Lapin and colleagues1 can be generalized to the Johns Hopkins Hospital AIDS Service is not clear. Their published abstract1 suggests that their population of foreign-born Latinos is twice that of blacks seen in the Los Angeles County Health Department clinic in which their study was conducted. Our comparison of U.S.-born blacks with U.S.-born whites is based on both patients' reports and medical records that either accompanied the patients or were obtained from their previous provider at a later date. In a 35 percent random sample, previous medical records were available 52 percent of the time for blacks and 56 percent of the time for whites who had not previously received antiretroviral therapy or PCP prophylaxis. Even so, we would point out that the medical record does not always reliably document medication use and that patients may report that they did not use a drug when offered because of cost or other factors. We also found a significantly greater mean corpuscular volume in patients who reported receiving zidovudine than in those who did not report such use, providing further corroboration. We would also note that our multivariate analysis controlled for several socioeconomic factors, particularly education. Socioeconomic status has been shown to correlate with patients' knowledge of drugs prescribed and advice given2. Patients' educational status may be more important than ethnic background with respect to communication with physicians3. Finally, there was a strong association reported between a lack of a primary care provider and failure to use these medications, suggesting an important factor influencing access to and receipt of care.
We do not deny that problems with recall, poor communication between the health care provider and the patient, or the patient's misunderstanding of names and reasons for prescribed medication can influence the patient's report of medication use. However, for the reasons described above, we do not believe these factors had a role in more than a relatively small number of our patients, and we believe it would be ill-advised to ignore well-documented differences in access to health care based on race.
3 ReferencesRichard D. Moore, M.D., M.H.S.
Richard E. Chaisson, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 212051
Lapin R, Sorvillo F, Kerndt P, et al. An evaluation of apparent disparities in medical care quality among minority AIDS patients in Los Angeles. Presented at the Ninth International Conference on AIDS, Berlin, Germany, June 6-11, 1993.
2
Bain DJ . Patient knowledge and the content of the consultation in general practice. Med Educ 1977;11:347-350
CrossRef | Web of Science | Medline3
Waitzkin H . Information giving in medical care. J Health Soc Behav 1985;26:81-101
CrossRef | Web of Science | Medline
- Citing Articles (3)
Citing Articles
1
Junling Wang, Ilene H. Zuckerman, Nancy A. Miller, Fadia T. Shaya, Jason M. Noel, C. Daniel Mullins. (2007) Utilizing New Prescription Drugs: Disparities among Non-Hispanic Whites, Non-Hispanic Blacks, and Hispanic Whites. Health Services Research 42:4, 1499-1519
CrossRef2
AC Ghani, CA Donnelly, RM Anderson. (2003) Patterns of antiretroviral use in the United States of America: analysis of three observational databases. HIV Medicine 4:1, 24-32
CrossRef3
Anne M. Rompalo, Nina Shah, Kenneth Mayer, Paula Schuman, Robert S. Klein, Dawn K. Smith, David Vlahov. (2001) Influence of Injection Drug Use Behavior on Reported Antiretroviral Therapy Use Among Women in the HIV Epidemiology Research Study: On-Site Versus Referral Care. JAIDS Journal of Acquired Immune Deficiency Syndromes 28:1, 28-34
CrossRef
