title: A preliminary study comparing attitudes toward hospice referral between African American and white American primary care physicians.
abstract: End-of-life (EOL) decision making is an integral component of high-quality health care. Factors influencing individual primary care physicians (PCPs) can affect their perspectives and referral preferences for EOL care. Numerous barriers have been cited, including patient and family readiness, physicians' comfort with discussing death, and the pursuit of a cure. This study explores another barrier by examining physician ethnicity and comparing the attitudes toward hospice referral between African American and white American primary care providers (PCPs). Training PCPs to efficiently transition from a curative model of care to a palliative model of care has the potential to increase the level of appropriate EOL care, increase hospice referral, and enhance patient and provider satisfaction; it is also fiscally prudent. This preliminary study aims to compare attitudes toward hospice referral and physicians' personal experiences with hospice between African American and white American PCPs.
  
  
  METHODS
  The survey tool was developed by PCPs at the Mayo Clinic Florida after a full literature review and consultation with hospice physicians, oncology specialists, and primary care colleagues from the residency programs at Mayo Minnesota and Mayo Arizona, with input from the Mayo Survey Office, and distributed to all physicians and residents in the departments of Family Medicine at via Mayo's intranet; Mayo's Midwest Regional Practices (245 physicians) received the survey via standard mail. The survey consisted of 17 questions regarding attitudes toward hospice referral and the one question regarding physicians' personal experience with hospice. The final sample size consisted of 167 white American physicians and 46 African American physicians. Responses were compared using a Wilcoxon rank sum test. P values ≤ 0.05 were considered statistically significant. All statistical analyses were performed using the SAS software package (SAS Institute, Cary, North Carolina).
  
  
  RESULTS
  The distributions of physician age, specialty, board certification, and years practicing medicine were similar between African American and white American physicians, while male gender was more common in white American physicians than African American physicians. Statistically significant differences in attitudes toward hospice between African American and white American physicians were observed for five of the 17 survey questions. There was a dramatic difference in the distribution of patient race between African American and white American physicians, raising the possibility that any differences between white American and African American physicians could be attributed to patient race, rather than physician race. Due to survey limits, larger studies involving more African American physicians are needed to address this topic.
  
  
  CONCLUSIONS
  The results of our preliminary study suggest that certain attitudes toward hospice referral may differ between African American and white American PCPs. If validated, further insight into this issue could lead to educational programs for PCPs that correct misperceptions.
authors.affiliation: Palliative Medicine Fellowship Program, Department of Family Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA. kevinache@yahoo.com
authors.forename: Kevin A
authors.initials: KA
authors.lastname: Ache
authors.forename: Robert P
authors.initials: RP
authors.lastname: Shannon
authors.forename: Michael G
authors.initials: MG
authors.lastname: Heckman
authors.forename: Nancy N
authors.initials: NN
authors.lastname: Diehl
authors.forename: Floyd B
authors.initials: FB
authors.lastname: Willis
mesh_terms: D000328:Adult; D001741:Black or African American / Q000523:psychology*; D000368:Aged; D000369:Aged, 80 and over; D001290:Attitude; D003625:Data Collection; D005260:Female; D017051:Hospice Care; D006801:Humans; D008297:Male; D008875:Middle Aged; D015146:Midwestern United States; D058007:Physicians, Primary Care / Q000523:psychology*; D012017:Referral and Consultation; D044465:White People / Q000523:psychology*