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Do Doctors Contribute to the Social Patterning of Disease?

McKinlay JB, Marceau, LD, Piccolo, RJ.
Medical Care Research and Review
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Data from the Boston Area Community Health Survey show that both undiagnosed signs and symptoms and diagnosed type 2 diabetes mellitus (T2DM) are patterned by socioeconomic status (SES). Such patterning is corroborated by National Health and Nutrition Examination Survey data for diagnosed T2DM. Complementary data from an experiment concerning clinical decision making show T2DM is patterned by race/ethnicity, following diagnosis by a physician. Undiagnosed signs and symptoms of T2DM in the community are patterned by SES (rather than race/ethnicity), but following diagnosis by primary care physicians they are patterned more by race/ethnicity (rather than by SES). Race/ethnicity and SES in the United States are almost totally confounded, such that measuring one is essentially also measuring the other. Physician patterning of T2DM by race/ethnicity, however, motivates the search for genetic and biophysiologic explanations and distracts attention from the more important contribution of SES circumstances to the prevalence of diabetes mellitus.

Diagnosed and Undiagnosed Diabetes by Race/Ethnicity AND SES

This figure displays the distribution of total diabetes by race/ethnicity, adding socioeconomic status (SES). The large difference between SES groups is evident in all three race/ethnic groups. A separate analysis of National Health and Nutrition Survey (NHANES) data produces a patterning by SES identical to that displayed here – corroborating the results from BACH. (Race/ethnicity chi-square: for lower SES: p=0.650; for middle SES: p=0.096; for upper SES: p<0.001)

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Marceau, L., McKinlay, J. B., Shackelton, R., & Link, C. (Epub ahead of print). The relative contribution of patient, provider and organizational influences to the appropriate diagnosis and management of diabetes mellitus. Journal of Evaluation in Clinical Practice.

Siegrist, J., Shackelton, R., Link, C., Marceau, L., von dem Knesebeck, O., McKinlay, J. (2010). Work stress of primary care physicians in the US, UK and German health care system. Social Science and Medicine, 71(2), 298-304.

Von dem Knesebeck, O., Bonte, M., Siegrist, J., Marceau, L., Link, C., & McKinlay, J. (2010). Diagnosis and therapy of depression in the elderly--influence of patient and physician characteristics. Psychother Psychosom Med Psychol, 60(3-4), 98-103.

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Von dem Knesebeck, O., Gerstenberger, E., Link, C., Marceau, L., Roland, M., Campbell, S., et al. (2010). Differences in the diagnosis and management of type 2 diabetes in 3 countries (US, UK, and Germany): Results from a factorial experiment. Medical Care, 48(4), 321-326.

Grant, R. W., Lutfey, K. E., Gerstenberger, E., Link, C. L., Marceau, L. D., & McKinlay, J. B. (2009). The decision to intensify therapy in patients with type 2 diabetes: results from an experiment using a clinical case vignette. The Journal of the American Board of Family Medicine, 22(5), 513-520.

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Shackelton, R. J., Marceau, L. D., Link, C. L., & McKinlay, J. B. (2009). The intended and unintended consequences of clinical guidelines. Journal of Evaluation in Clinical Practice, 15(6), 1035-1042.

Shackelton, R., Link, C., Marceau, L., & McKinlay, J. (2009). Does the culture of a medical practice affect the clinical management of diabetes by primary care providers? Journal of Health Services Research and Policy, 14(2), 96-103.

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Link, C.L., Stern, T.A., Piccolo, R.S., Marceau, L.D., Arber, S., Adams, A., Siegrist, J., von dem Knesebeck, O., McKinlay, J.B. (2011). Diagnosis and Management of Depression in 3 Countries: Results From a Clinical Vignette Factorial Experiment. The Primary Care Companion for CNS Disorders, 13(5), e1-e7.

Lutfey, K.E., Campbell, S.M., Marceau, L.D., Roland, M.O., McKinlay, J.B. (2012). Influences of organizational features of healthcare settings on clinical decision making: Qualitative results from a cross-national factorial experiment. Health, 16(1), 40-56.

Marceau L, McKinlay J, Shackelton, R, Link C. (2011). The relative contribution of patient, provider and organizational influences to the appropriate diagnosis and management of diabetes mellitus. Journal of Evaluation in Clinical Practice, 17(6),1122-8.

McKinlay, J.B., Marceau, L.D., Piccolo, R.J. (2012). Do doctors contribute to the social patterning of disease? The case of race/ethnic disparities in diabetes mellitus. Medical Care Research and Review, 69(2),176-93.

McKinlay J.B., & Marceau, L.D. (2011). New wine in an old bottle: does alienation provide an explanation of the origins of physician discontent? International Journal of Health Services, 41(2), 301-35.

Oka, M., Link, C.L., Kawachi, I. (2011). Disparities in the prevalence of obesity in Boston: results from the Boston Area Community Health (BACH) survey. Public Health Reports, 126(5), 700-7.

Shackelton-Piccolo, R., McKinlay, J.B., Marceau, L.D., Goroll, A.H., Link, C.L. (2011). Differences between internists and family practitioners in the diagnosis and management of the same patient with coronary heart disease. Medical Care Research and Review, 68(6), 650-66.

Welch, L.C., Lutfey, K.E., Gerstenberger, E., Grace, M. (2012). Gendered uncertainty and variation in physicians' decisions for coronary heart disease: the double-edged sword of "atypical symptoms". Journal of Health and Social Behavior, 53(3), 313-28.

Welch, L.C., Botelho, E.M., Joseph, J.J., Tennstedt, S.L. (2012). A qualitative inquiry of patient-reported outcomes: the case of lower urinary tract symptoms. Nursing Research, 61(4), 283-90.

Welch, L.C., Botelho, E.M., Tennstedt, S.L. (2011). Race and ethnic differences in health beliefs about lower urinary tract symptoms. Nursing Research, 60(3), 165-72.

McKinlay, J.B. & Marceau, L.D. (2012). From cottage industry to a dominant mode of primary care: stages in the diffusion of a health care innovation (retail clinics). Social Science & Medicine, 75(6), 1134-41.

Heretic's Corner
10/4/2011 - Posted by NERI Upstream
For example, how useful is it to encourage households in poverty (experiencing food insecurity) to consume more costly “healthful” diets (lean meats, whole grains and fresh vegetables and fruit). The examples are endless............