Discussion Questions

• ■
  

  What were the study’s objectives?

  
  
• ■
  

  What was the study’s design?

  
  
• ■
  

  What were the main findings?

  
  
• ■
  

  What were the study’s strengths and limitations?

  
  
• ■
  

  Will this study change your approach when recommending contraceptives?

Within the first year of typical use, fewer than 1 woman per hundred will become pregnant while using intrauterine contraception (IUC); the pregnancy rates are 0.8% with the copper T 380 A and 0.2% with the levonorgestrel-releasing intrauterine system. After the etonogestrel implant (first-year pregnancy rate, 0.05%), IUC is the most effective form of reversible contraception available in the United States. Its success does not depend on the patient’s actions, let alone her race, ethnicity, or socioeconomic status (SES). Yet, such demographic factors might influence whether she receives IUC from her physician.

Race, ethnicity, and SES are well known to figure into health care outcomes. But increasingly, researchers are investigating whether physicians are unwitting contributors to existing disparities. In a new study, Dehlendorf and colleagues examined whether physicians’ recommendations for a birth control method were affected by patients’ race/ethnicity or SES.

The authors noted that choosing a contraceptive is a complex task for patients, and the physician’s counseling and recommendation have a powerful effect. Their work, judged to be important and timely by Journal Club members, explored whether physicians’ subconscious biases or assumptions might encroach on the decision-making process, influencing access to the most effective forms of contraception.

Video conference

Specifically, Dehlendorf et al tried to determine whether patient race/ethnicity and SES affected the providers’ recommendations for the levonorgestrel IUC. They used a randomized factorial study design to evaluate multiple factors simultaneously. For example, in the classic 2-by-2 study design, a researcher can evaluate the effect of the 2 factors studied, as well as the interaction of both factors. In this study, the investigators examined the independent and joint effects of race/ethnicity, SES, and gynecologic history. Race had 3 levels: white, black, or Latina. SES had 2 levels: low or high (upper middle class). Gynecologic history had 2 levels: the patients representing women considered to have no risk had a history of vaginal delivery with no history of sexually transmitted disease. Those representing women with so-called risk factors either had a history of vaginal delivery and pelvic inflammatory disease or were nulliparous. All permutations of these 3 factors resulted in 18 possible combinations. The authors produced a standardized patient video for each.

The featured patients shared all other historical traits: they were 27-years-old, monogamous, normotensive, and interested in postponing pregnancy for a few years. Each had recently tested negative for gonorrhea and chlamydia, and each had a normal Papanicolaou test. The clinician participants, who were recruited at regional and national medical conferences for obstetrician-gynecologists and family medicine practitioners, were not informed of the primary study hypothesis and were told the patients had insurance coverage for all contraceptive options.

Participants were randomized in blocks of 18—1 physician in each block viewed just 1 of the videos. On average, each video was viewed 29 times. This approach offered an efficient way to examine the effects of race/ethnicity and SES—and interactions between them. It also allowed for strict control of sociodemographic characteristics and clinical reporting, and it reduced confounding by these elements. Randomization was intended to minimize systematic biases in respondents. Overall, this was successful with the single exception that compared with female providers, male providers assigned to standardized patients with perceived risk factors were more likely to be assigned the black patient and less likely to be assigned the Latina patient.