What was the project about?
Treatment decisions for depression and diabetes are complex. Talking about and paying attention to patient treatment preferences may improve patients’ health as well as their ability to take treatment as recommended. Previous studies have shown that patients’ preferences for treatments vary by race and ethnicity. For Black and Hispanic or Latino patients, factors such as past discrimination in health care may affect treatment preferences.
Researchers can use experiments to learn what patients prefer. Discrete choice experiments, or DCEs, describe care options with different features, such as type of treatments offered or out-of-pocket costs. Patients fill out surveys about which options they prefer. From their choices, researchers learn what’s most important to patients.
In this study, the research team used a DCE to learn what types of treatment adults of different races and ethnicities preferred for depression and diabetes. Treatments included
- Medicine only, talk therapy only, or both for depression
- Medicine only, behavior change only, or both for diabetes
The research team also looked at whether experiences of past discrimination in health care affected patient preferences.
What were the results?
For both depression and diabetes, Black and Hispanic or Latino adults didn’t have treatment preferences. White adults preferred medicine only for both.
Black and Hispanic or Latino adults were more likely to experience discrimination in health care than Whites. Among those who reported past discrimination,
- Black and Hispanic or Latino adults preferred medicine only for depression.
- Black and White adults preferred behavior change only for diabetes.
Who was in the study?
The study included 1,512 adults with depression, diabetes, or both. Of these, 33 percent were Black, 33 percent were Hispanic/Latino, and 33 percent were White. All were part of a national survey panel.
What did the research team do?
The research team developed a survey. The survey asked adults to choose between two doctors for mental health or diabetes care. The survey had 18 comparisons. In each, the doctors differed in five features, such as treatment offered or out-of-pocket cost. The survey also asked about experiences with discrimination in health care.
Patient advocates, community health workers, and patient experience professionals helped design and conduct the study.
What were the limits of the project?
The research team looked at only one point in time; they can’t say for sure that discrimination led to patients’ treatment preferences. The study compared doctors on a limited set of features. These features may not capture actual treatment decisions.
Future research could look at how doctors can talk with patients about treatment preferences and past discrimination.
How can people use the results?
Doctors can use these results when considering how past experiences of discrimination may affect patients’ treatment preferences.
For depression and diabetes care, knowing and attending to patients’ treatment preferences improves patient outcomes and treatment adherence. Previous studies have shown that patient preferences for depression treatment vary by race and ethnicity. For Black and Hispanic or Latino patients, factors such as discrimination in past healthcare encounters may directly influence treatment preferences or change how patients value different treatment options in trade-offs with other factors.
Discrete choice experiments (DCEs) may be used to better understand patient treatment preferences. In a DCE, respondents make a series of choices between two or more hypothetical options. Each option is described by a set of attributes, and each attribute has a range of values. By analyzing which options respondents choose when presented with multiple combinations of attributes, researchers can estimate how important each attribute is to the respondents’ overall preferences.
To evaluate the extent to which depression and diabetes treatment preferences vary by race and ethnicity and by experiences of prior discrimination in health care
|Data Sources and Data Sets||1,512 adults with diabetes, moderate to severe depression, or both|
|Analytic Approach||Conditional logit regression modeling|
|Treatment modality preferences|
This DCE compared the extent to which experiences of discrimination in health care influenced treatment preferences in patients of different races and ethnicities with moderate to severe depression or diabetes.
Patients completed a survey in which they chose between two hypothetical depression care providers in 18 comparisons. The providers in each comparison varied in terms of five provider attributes, including treatment offered, provider reliability, use of understandable language, travel time, and out of-pocket costs. Each attribute had a range of possible values. For example, treatment offered for depression included medication only, talk therapy only, or both; treatment offered for diabetes included medication only, behavioral modification only, or both. The survey also asked respondents whether they had experienced discrimination in health care.
The study included 1,512 adults with depression or diabetes or both who were members of a national survey panel. Of these adults, 33% were Black, 33% were Hispanic/Latino, and 33% were White.
Patient advocates, community health workers, and patient experience professionals helped design the study and provided feedback throughout.
On average, Black and Hispanic/Latino respondents did not have significant treatment preferences for diabetes or depression. White respondents preferred medication only for both depression (p<0.001) and diabetes (p<0.001).
Black and Hispanic/Latino respondents were significantly more likely to experience healthcare discrimination than Whites (both p<0.001). Among respondents who reported past healthcare discrimination, Black and Hispanic/Latino respondents preferred medication for depression (p<0.05 or below), and Black and White respondents preferred behavioral modification for diabetes (p<0.05 or below).
Because this study was cross-sectional, researchers cannot say with certainty that respondents’ experiences with healthcare discrimination caused treatment modality preferences. The DCE included limited provider attributes and may not have reflected the complexity of actual patient decisions.
Conclusions and Relevance
In this study, past experiences of healthcare discrimination were associated with treatment preferences for diabetes and depression.
Future Research Needs
Future research could explore how providers can elicit patient preferences and discrimination experiences in treatment decisions.
Final Research Report
View this project's final research report.
Related Journal Citations
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers asked for more information about the sampling strategy for the national survey component of the study given the very high response rate, which is unusual for such surveys. The researchers explained that they used a nationally representative survey panel, where members received compensation for the surveys they completed.
- The reviewers asked for more explanation of the proposed mediation analyses in the study. The researchers explained that conceptually, they hypothesized and sought to investigate whether the effect of perceived discrimination on patient-reported quality of medical care was mediated by the therapeutic relationship between clinician and patient. The researchers acknowledged that they could not fully assess the mediational hypothesis because the timing of data collection for all three constructs did not allow for the researchers to test causation. Instead, the researchers used established methods for testing relationships between such constructs in cross-sectional data.
Conflict of Interest Disclosures
Patient / Caregiver Partners
- Jonathan Delman, PhD, JD, MPH
- Ms. Valeria Chambers and Ms. Catherine Quinerly of the Transformation Center
Other Stakeholder Partners
- Ms. Ziva Mann
- Chong-Min Fu-Sosnaud, ScM
- Danny McCormick, MD, MPH
Study Registration Information
Final Research Report
View this project's final research report.
- Has Results