Influence of Patients' Socioeconomic Status on Clinical Management Decisions: A Qualitative Study
Open accessAbstract
PURPOSE: Little is known about how patients' socioeconomic status (SES) influences physicians' clinical management decisions, although this information may have important implications for understanding inequities in health care quality. We investigated physician perspectives on how patients' SES influences care. METHODS: The study consisted of in-depth semistructured interviews with primary care physicians in Connecticut. Investigators coded interviews line by line and refined the coding structure and interview guide based on successive interviews. Recurrent themes emerged through iterative analysis of codes and tagged quotations. RESULTS: We interviewed 18 physicians from varied practice settings, 6 female, 9 from minority racial backgrounds, and 3 of Hispanic ethnicity. Four themes emerged from our interviews: (1) physicians held conflicting views about the effect of patient SES on clinical management, (2) physicians believed that changes in clinical management based on the patient's SES were made in the patient's interest, (3) physicians varied in the degree to which they thought changes in clinical management influenced patient outcomes, and (4) physicians faced personal and financial strains when caring for patients of low SES. CONCLUSIONS: Physicians indicated that patient SES did affect their clinical management decisions. As a result, physicians commonly undertook changes to their management plan in an effort to enhance patient outcomes, but they experienced numerous strains when trying to balance what they believed was feasible for the patient with what they perceived as established standards of care.
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Written from the paper’s full text.
TL;DR
In interviews with 18 Connecticut primary care physicians, all described changing clinical management because of patient socioeconomic status, often intending to make care more affordable, feasible, or comprehensible. Physicians were conflicted about SES influencing care and reported personal and financial strains when balancing feasibility with standards.
Key findings
- Four recurrent themes emerged: physicians held conflicting views about SES effects on clinical management; they believed changes were made in the patient’s interest; they varied in whether changes influenced outcomes; and they faced personal and financial strains caring for low-SES patients.
- Every physician described situations in which they changed care because of patient SES, including using less-expensive medications, avoiding specialist referrals, postponing testing, less aggressive diabetes management, and altering communication.
- Some physicians believed tailored changes did not compromise outcomes, such as prescribing generic rather than brand-name medication, while others said financial limits led to worse outcomes, such as difficulty controlling chronic pain with less-expensive medications.
- Physicians reported strains including no longer accepting new Medicaid or uninsured patients, extra work to obtain free medications or specialty referrals, and concerns about performance measurement.
Methods
- Qualitative study using 18 semistructured interviews with primary care physicians in Connecticut who care for Medicaid patients; the sample included 6 women, 9 physicians from minority racial backgrounds, and 3 of Hispanic ethnicity, with 5 to 23 years of clinical experience.
- Sampling combined random identification from the Medicaid primary care pool (14 contacted, 11 agreed), purposeful selection for variation in race/ethnicity, practice type, and setting (4 contacted, all agreed), and snowball sampling for minority physicians and those caring for veterans (3 identified, all agreed).
- Analysis used line-by-line open coding by three investigators, negotiated consensus, iterative refinement of the coding structure and interview guide, and constant comparative/editing analysis until thematic saturation; Atlas-ti was used to select verbatim quotations.
Limitations
- Stated: the study did not use theoretical iterative sampling and was limited to physicians from a single state caring for adult patients only.
- Stated: only physicians were interviewed, so patients’ perspectives on how SES influences clinical management may differ.
- Stated: interviewers were primary care physicians experienced in caring for low-SES populations, which may have influenced interviews and interpretation; a third investigator coded all interviews. Evident: the sample was small (18 physicians) and findings rely on self-reported accounts rather than direct measurement of patient outcomes.
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Integrity signals
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Cites
Statistics
Claims the paper makes
0 of 16 cited sources checked · 0 supported · 0 flagged
- Findingown data
Physicians faced personal and financial strains when caring for patients of low SES.
“physicians faced personal and fi nancial strains when caring for patients of low SES”
Quote in the paperNot a substantial claim - Findingown data
Most physicians' statements divulged conflicted views about the influence of patient SES on clinical management.
“Most physicians' statements, however, divulged more confl icted views about the infl uence of patient SES on clinical management.”
Quote in the paperSubstantial claim - Findingown data
Physicians believed that changes in clinical management based on the patient's SES were made in the patient's interest.
“physicians believed that changes in clinical management based on the patient's SES were made in the patient's interest”
Quote in the paperSubstantial claim - Findingown data
Physicians commonly undertook changes to their management plan in an effort to enhance patient outcomes.
“physicians commonly undertook changes to their management plan in an effort to enhance patient outcomes”
Quote in the paperSubstantial claim - Findingown data
Our findings identify a number of ways that physicians change care based on their patients' SES.
“Our fi ndings identify a number of ways that physicians change care based on their patients' SES.”
Quote in the paperSubstantial claim
- Findingown data
Physicians held conflicting views about the effect of patient SES on clinical management.
“physicians held confl icting views about the effect of patient SES on clinical management”
Quote in the paperNot a substantial claim - Findingown data
Physicians indicated that patient SES did affect their clinical management decisions.
“Physicians indicated that patient SES did affect their clinical management decisions.”
Quote in the paperSubstantial claim - Findingown data
Physicians experienced numerous strains when trying to balance what they believed was feasible for the patient with what they perceived as established standards of care.
“they experienced numerous strains when trying to balance what they believed was feasible for the patient with what they perceived as established standards of care.”
Quote in the paperSubstantial claim - Findingcitation
Many of the physicians no longer accept Medicaid patients.
“Many of the physicians no longer accept Medicaid patients, a phenomenon recently documented on a national level 38”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [38]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Findingown data
Every physician within the diverse group described situations in which they changed their care because of a patient's SES.
“Every physician within our diverse group described situations in which they changed their care because of a patient's SES.”
Quote in the paperSubstantial claim - Findingown data
Physicians described tailoring care based on a patient's SES as a way to mitigate the negative impact of SES on patient outcomes.
“Finally, physicians described tailoring care based on a patient's SES as a way to mitigate the negative impact of SES on patient outcomes.”
Quote in the paperSubstantial claim - Findingown data
In other cases, physicians indicated the clinical management decisions made to accommodate a patient's low SES could compromise outcomes.
“In other cases, however, physicians indicated the clinical management decisions made to accommodate a patient's low SES could compromise outcomes.”
Quote in the paperSubstantial claim - Findingown data
In changing their clinical management decisions to account for a patient's SES, physicians experienced tension between maintaining a consistent standard of care and providing care that was not the standard of care but what they believed was appropriate given a patient's SES.
“In changing their clinical management decisions to account for a patient's SES, physicians experienced tension between an ideal of maintaining a consistent standard of care for all patients and providing care that was not the standard of care but what they believed was appropriate given a patient's SES.”
Quote in the paperSubstantial claim - Findingown data
The constraint physicians experienced when a patient's SES limited feasible care plans was a source of considerable stress to the interviewed physicians.
“This constraint was a source of considerable stress to the physicians we interviewed.”
Quote in the paperSubstantial claim - Findingown data
Our interviews exposed the personal and financial strains that physicians experience when caring for populations of patients of low SES.
“Our interviews exposed the personal and fi nancial strains that physicians experience when caring for populations of patients of low SES.”
Quote in the paperSubstantial claim - Findingown data
Physicians were conflicted about the concept that the patient's SES influenced clinical management.
“physicians were nonetheless confl icted about the concept that the patient's SES infl uenced clinical management.”
Quote in the paperSubstantial claim - Findingown data
Physicians varied in the degree to which they thought changes in clinical management influenced patient outcomes.
“physicians varied in the degree to which they thought changes in clinical management infl uenced patient outcomes”
Quote in the paperNot a substantial claim - Findingown data
For some physicians, concerns about not maintaining standards of care and about worse patient outcomes were compounded by increased attention to performance measurement.
“For some physicians concerns about not maintaining standards of care and about worse patient outcomes were compounded by increased attention to performance measurement”
Quote in the paperNot a substantial claim - Findingown data
Most of the changes physicians described as based on a patient's SES were made to provide care that was more affordable, feasible, or comprehensible for a patient.
“Most of the changes physicians described as based on a patient's SES were made to provide care that was more affordable, feasible, or comprehensible for a patient.”
Quote in the paperSubstantial claim - Interpretationreasoning
Many of the changes physicians described may contribute to observed disparities in health care quality.
“Many of the changes that physicians describedless aggressive diabetes management, postponement of testing, or use of less than ideal or nonstandard treatments as a result of fi nancial limitations-may contribute to observed disparities in health care quality.”
Quote in the paperSubstantial claim - Premisecitation
Maintaining a physician workforce willing to care for poor and vulnerable patient groups is becoming more difficult.
“As national trends indicate, maintaining a physician workforce willing to care for poor and vulnerable patient groups is becoming more diffi cult, 39”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [39]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Premisecitation
Patients of low SES receive worse diabetes care.
“worse diabetes care, 1,2,15”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [1]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [2]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [15]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Premisecitation
Patients of low SES receive fewer preventive services.
“Patients of low SES receive fewer preventive services, 1,6,8,12”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [1]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [6]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [8]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Interpretationcitation
Some changes made by physicians to accommodate low SES, such as adapting communication to improve understanding and adherence, align with the priorities of patient-centered care.
“Some changes made by physicians to accommodate low SES, such as adapting communication to improve understanding and adherence, align with the priorities of patient-centered care.[33][34][35]”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites [33]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [34]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [35]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Interpretationreasoning
Observed disparities may in part result from physician actions made in what they believe to be a patient's interest.
“These results also suggest that observed disparities may in part result from physician actions made in what they believe to be a patient's interest.”
Quote in the paperSubstantial claim - Interpretationreasoning
It is not clear whether the changes in clinical management made in a patient's interest improve or worsen patient outcomes.
“Although interviewed physicians described changes in clinical management as being made in a patient's interest, it is not clear whether these changes improve or worsen patient outcomes.”
Quote in the paperSubstantial claim - Premisecitation
SES disparities exist even among fully insured patients.
“Moreover, SES disparities exist even among fully insured patients.4,5,8,13”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites [4]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [5]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [8]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Premisecitation
Patients of low SES receive fewer indicated cardiac interventions.
“fewer indicated cardiac interventions.7,16”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [7]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [16]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Classified as probably not a substantial claim. 6
- May combine two claims. 5
- The quote only partly states this claim. 1
Classified as probably not a substantial claim.
Findingown dataIn some cases, physicians believed that, although they provided different care for patients of low SES compared with patients of higher SES, patient outcomes did not differ.
“In some cases, physicians believed that, although they provided different care for patients of low SES when compared with patients of higher SES, patient outcomes did not differ.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataTo make care more affordable, physicians described using less-expensive medications, avoiding specialist referrals, trying to accomplish more in a single visit, and postponing testing.
“To make care more affordable to patients as a result of income or insurance restrictions, for instance, physicians described using less-expensive medications, avoiding specialist referrals, trying to accomplish more in a single visit, and postponing testing.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Findingown dataSome physicians stated that they could no longer afford to accept new Medicaid or uninsured patients and questioned the sustainability of the current health care system.
“Furthermore, some physicians stated that they could no longer afford to accept new Medicaid or uninsured patients and questioned the sustainability of the current health care system.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Study design and conductreasoningAll interviews were additionally coded by a third investigator, a health services researcher with substantial qualitative research experience and expertise in quality of care.
“For this reason, all interviews were additionally coded by a third investigator, a health services researcher with substantial qualitative research experience and expertise in quality of care.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductreasoningThe interviewers' parallel education and experience may have contributed to their ability to establish rapport but may also have influenced their approach to interviews and interpretation of data.
“their parallel education and experience may have contributed to their ability to establish rapport with the physicians interviewed but may also have infl uenced both their approach to the interviews and their interpretation of the data.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing), S4 (based). The quote only partly states this claim.
Interpretationnone givenPatients' perspectives on how SES influences clinical management may be different from physicians' perspectives.
“patients' perspectives on how SES infl uences clinical management may be different.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
InterpretationreasoningThe scope of our findings is limited to the perspective of physicians.
“Although the scope of our fi ndings is limited to the perspective of physicians”
Quote in the paperSubstantial claimMay combine two claims.
InterpretationreasoningThese changes may contribute to measured socioeconomic disparities in health care; however, many changes are made to enhance patient outcomes given the constraints associated with low SES.
“These changes may contribute to measured socioeconomic disparities in health care; however, many changes are made to enhance patient outcomes given the constraints associated with low SES.”
Quote in the paperSubstantial claimMay combine two claims.
InterpretationreasoningTailoring care based on financial limitations, such as providing a less effective but more affordable medication, may be appropriate, but it does not necessarily reflect the values or health beliefs of a patient.
“Tailoring care based on fi nancial limitations, such as providing a less effective but more affordable medication, may be appropriate, but it does not necessarily refl ect the values or health beliefs of a patient, as is central to most defi nitions of patient-centered care.”
Quote in the paperSubstantial claim
The paper relies on this without support.
Little is known about how low SES influences physicians' decision making regarding clinical management and how SES may contribute to disparities in quality of care.
“Little is known, however, about how low SES ultimately infl uences physicians' decision making regarding clinical management of patients and thus how SES may contribute to measured disparities in quality of care.”
The paper relies on this without support.
Current quality measures do not provide guidance or adjustment for the tailoring of care that interviewed physicians believed best met the needs of their patients.
“Current quality measures do not provide guidance or adjustment for the tailoring of care that interviewed physicians believed best met the needs of their patients.”
The paper relies on this without support.
Although financial limitations commonly influence clinical practice, physicians are without an evidence base to guide such decisions.
“Although fi nancial limitations commonly infl uence clinical practice, physicians are without an evidence base to guide such decisions.”
The paper relies on this without support.
Physicians' self-reports in interviews accurately reflect their clinical management decisions.
“We chose this method of research in the belief that physician participants were most likely to respond candidly in the context of one-on-one discussion with a physician interviewer.”
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“Four themes emerged from our interviews: (1) physicians held confl icting views about the effect of patient SES on clinical management, (2) physicians believed that changes in clinical management based on the patient’s SES were made in the patient’s interest, (3) physicians varied in the degree to which they thought c…”
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“Four themes emerged from our interviews: (1) physicians held confl icting views about the effect of patient SES on clinical management, (2) physicians believed that changes in clinical management based on the patient’s SES were made in the patient’s interest, (3) physicians varied in the degree to which they thought c…”
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“Second, individual insurable income, the only socioeconomic indicator available for analysis, as used to define the SES gradient, may underestimate a subject’s real income; it might also have been more appropriate to use family disposable income, occupation status, or education level to measure socioeconomic status ha…”
BackgroundInfluentialSociodemographic biases in medical decision making by large language models
Omar, M., Soffer, S., Agbareia, R., Bragazzi, N. L., Apakama, D. U., Horowitz, C. R., Charney, A. W., Freeman, R., Kummer, B., Glicksberg, B. S., et al. (2025) · Nature Medicine · doi:10.1038/s41591-025-03626-6 · Cited by 173 · see citing works
“Although real-world economic status can influence care intensity 27,28 , the scenario presented here was clinically identical, with only sociodemographic attributes changed.”
Declarative process mining in healthcare
Rovani, M., Maggi, F. M., de Leoni, M., et al. (2015) · Expert Systems with Applications · doi:10.1016/j.eswa.2015.07.040 · Cited by 135 · see citing works
“Sometimes, clinical decisions can also be influenced by the cost of a treatment and by the patients’ socioeconomic status [19].”
BackgroundBrowne, J. A., Novicoff, W. M., & D’Apuzzo, M. R. (2014) · Journal of Bone and Joint Surgery · doi:10.2106/jbjs.n.00133 · Cited by 132 · see citing works
“Mean age (range) (yr) 56 (7-92) 56 (7-92) NA”
Decision Making Criteria in Oncology
Glatzer, M., Panje, C. M., Sirén, C. A., Čihorić, N., & Putora, P. M. (2018) · Oncology · doi:10.1159/000492272 · Cited by 127 · see citing works
Majumder, S. (2021) · Journal of Family Medicine and Primary Care · doi:10.4103/jfmpc.jfmpc_600_21 · Cited by 116 · see citing works
Association of Income Disparities with Patient-Reported Healthcare Experience
Okunrintemi, V., Khera, R., Spatz, E. S., Salami, J., Elizondo, J. V., Warraich, H. J., Virani, S. S., Blankstein, R., Blaha, M. J., Pawlik, T. M., et al. (2019) · Journal of General Internal Medicine · doi:10.1007/s11606-019-04848-4 · Cited by 92 · see citing works
Self-citationGuilfoyle, R., Demers, A., Bredeson, C., Richardson, E., Rubinger, M., Szwajcer, D., & Seftel, M. D. (2008) · Bone Marrow Transplantation · doi:10.1038/bmt.2008.300 · Cited by 87 · see citing works
Juhn, Y. J., Ryu, E., Wi, C.-I., King, K. S., Malik, M., Romero-Brufau, S., Weng, C., Sohn, S., Sharp, R. R., & Halamka, J. D. (2022) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocac052 · Cited by 83 · see citing works
Disparities in access to health care in three French regions
Gusmano, M. K., Weisz, D., Rodwin, V. G., et al. (2013) · Health Policy · doi:10.1016/j.healthpol.2013.07.011 · Cited by 80 · see citing works
Kovshoff, H., Williams, S. J., Vrijens, M., Danckaerts, M., Thompson, M. J. J., Yardley, L., Hodgkins, P., & Sonuga-Barke, E. J. S. (2011) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-011-0235-8 · Cited by 65 · see citing works
Bajaj, J. S., Riggio, O., Allampati, S., Prakash, R., Gioia, S., Onori, E., Piazza, N., Noble, N. A., White, M. B., & Mullen, K. D. (2013) · Clinical Gastroenterology and Hepatology · doi:10.1016/j.cgh.2013.05.010 · Cited by 64 · see citing works
Shared decision making with vulnerable populations in the emergency department
Castaneda‐Guarderas, A., Glassberg, J., Grudzen, C. R., Ngai, K. M., Samuels‐Kalow, M. E., Shelton, E., Wall, S. P., & Richardson, L. D. (2016) · Academic Emergency Medicine · doi:10.1111/acem.13134 · Cited by 63 · see citing works
Buawangpong, N., Pinyopornpanish, K., Jiraporncharoen, W., Dejkriengkraikul, N., Sagulkoo, P., Pateekhum, C., & Angkurawaranon, C. (2020) · BMC Family Practice · doi:10.1186/s12875-020-01183-0 · Cited by 60 · see citing works
A systematic review of reasons for and against asking patients about their socioeconomic contexts
Moscrop, A., Ziébland, S., Roberts, N. W., & Papanikitas, A. N. (2019) · International Journal for Equity in Health · doi:10.1186/s12939-019-1014-2 · Cited by 57 · see citing works
Health Care Reform and Equity: Promise, Pitfalls, and Prescriptions
Fiscella, K. A. (2011) · The Annals of Family Medicine · doi:10.1370/afm.1213 · Cited by 56 · see citing works
Randén, M., Frankling, M. H., Runesdotter, S., & Strang, P. M. (2013) · Acta Oncologica · doi:10.3109/0284186x.2012.758872 · Cited by 52 · see citing works
Rajeshuni, N., Zubair, T., Ludwig, C. A., Moshfeghi, D. M., & Mruthyunjaya, P. (2020) · JAMA Ophthalmology · doi:10.1001/jamaophthalmol.2020.2254 · Cited by 47 · see citing works
Dumesnil, H., Cortaredona, S., Verdoux, H., Sebbah, R., Paraponaris, A., & Verger, P. (2012) · PLoS ONE · doi:10.1371/journal.pone.0052429 · Cited by 46 · see citing works
“These case-vignettes were designed in several versions that varied only according to patient gender and SES (blue collar/white collar) and MD severity (mild/severe).”
BackgroundInfluentialAelbrecht, K., Rimondini, M., Bensing, J., Moretti, F., Willems, S., Mazzi, M., Fletcher, I., & Deveugele, M. (2015) · Advances in Health Sciences Education · doi:10.1007/s10459-014-9569-6 · Cited by 45 · see citing works
“They also react with less affect and take less initiative to increase their participation in the decision making process (Verlinde et al. 2012; Longtin et al. 2010; Smith et al. 2009; Bernheim et al. 2008).”
BackgroundSocioeconomic Status Affects Pulmonary Hypertension Disease Severity at Time of First Evaluation
Talwar, A., Talwar, A., Sahni, S., et al. (2016) · Pulmonary Circulation · doi:10.1086/686489 · Cited by 45 · see citing works
“In support of this trend, a qualitative study by Bernheim et al.26 found that for patients with a lower SES, physicians, to make health care more affordable, would use less expensive medications, avoid specialist referral, accomplish more in a single visit, and postpone testing.”
MethodJob, C., Adenipekun, B., Cleves, A., Gill, P., & Samuriwo, R. (2024) · BMJ Open · doi:10.1136/bmjopen-2023-081723 · Cited by 44 · see citing works
Fobil, J. N., May, J., & Kraemer, A. (2010) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph7010125 · Cited by 44 · see citing works
“Several review articles have reported widening intra-urban differentials in environmental quality conditions in the poor countries [2,4-7,9,10,16-23].”
BackgroundInfluentialAljarallah, N. A., Almuqbil, M. S., Alshehri, S., et al. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2022.1077147 · Cited by 41 · see citing works
Moledina, A., & Tang, K. L. (2021) · CJC Open · doi:10.1016/j.cjco.2021.02.006 · Cited by 40 · see citing works
“Although some physicians believe that this tailoring of clinical decisions based on SES does not lead to disparities in outcomes, others acknowledge that this type of practice is not ideal but may be necessary to mitigate even worse outcomes in low-SES patients.(40) That is, physicians may provide what they feel is “a…”
BackgroundInfluentialHajjaj, F. M., Salek, S., Basra, M. K. A., & Finlay, A. Y. (2010) · British Journal of Dermatology · doi:10.1111/j.1365-2133.2010.09868.x · Cited by 39 · see citing works
Birninger, N., Bornhäuser, M., Schaich, M. A., Ehninger, G., & Schetelig, J. (2011) · Transplantation and Cellular Therapy · doi:10.1016/j.bbmt.2011.06.009 · Cited by 40 · see citing works
“The apparent differences between our cohort and the FHCRC cohort may also be related to more complex reasons such as the socioeconomic status [23].”
BackgroundAngerer, S. V., Waibel, C., & Stummer, H. (2018) · American Journal of Health Economics · doi:10.1162/ajhe_a_00124 · Cited by 39 · see citing works
“…or takes less time since they are in better health or because they have better communication skills and thus can communicate their health problem better (Howard et al. 2006; Willems et al. 2005) or if they think that patients with lower socioeconomic status are noncompliant (Bernheim et al. 2008).”
Rajeshuni, N., Whittemore, A. S., Ludwig, C. A., et al. (2019) · American Journal of Ophthalmology · doi:10.1016/j.ajo.2019.04.015 · Cited by 39 · see citing works
The Effect of Payer Type on Clinical Outcomes in Total Knee Arthroplasty
Rosenthal, B. D., Hulst, J. B., Moric, M. M., et al. (2013) · The Journal of Arthroplasty · doi:10.1016/j.arth.2013.06.010 · Cited by 38 · see citing works
Nordenvall, R., Marcano, A. I., Adami, J., Palme, M. O., Mattila, V. M., Bahmanyar, S., & Felländer‐Tsai, L. (2016) · The American Journal of Sports Medicine · doi:10.1177/0363546516672651 · Cited by 38 · see citing works
“Furthermore, there are several ways by which physician factors may result in the delivery of different types of care to patients in different SES levels,(31,36,37,39) and some physicians have reported that in certain situations, they deliberately change their care because of a patient’s SES, describing that these chan…”
BackgroundDoes Race/Ethnicity Really Matter in Adult Neurogenics?
Ellis, C. (2009) · American Journal of Speech-Language Pathology · doi:10.1044/1058-0360(2009/08-0039 · Cited by 37 · see citing works
Karran, E. L., Fryer, C. E., Middleton, J. W., & Moseley, G. L. (2022) · Journal of Pain · doi:10.1016/j.jpain.2022.04.001 · Cited by 39 · see citing works
Disparities in Opioid Pain Management for Long Bone Fractures
Benzing, A. C., Bell, C., Derazin, M., Mack, R., & MacIntosh, T. (2020) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-020-00701-1 · Cited by 34 · see citing works
Psychosocial information use for clinical decisions in diabetes care
Senteio, C. R., Adler‐Milstein, J., Richardson, C. R., & Veinot, T. C. (2019) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocz053 · Cited by 33 · see citing works
“Several prior studies in the US suggest that psychosocial factors, particularly patient socioeconomic status, may influence clinicians’ treatment decisions as they seek to make treatment more affordable.(56) Similar to this study, others have found that physicians may consider medication costs and patient out-of-pocke…”
BackgroundSharing online clinical notes with patients: implications for nocebo effects and health equity
Blease, C. R. (2022) · Journal of Medical Ethics · doi:10.1136/jme-2022-108413 · Cited by 29 · see citing works
Bias in Reinforcement Learning: A Review in Healthcare Applications
Smith, B., Khojandi, A., & Vasudevan, R. K. (2023) · ACM Computing Surveys · doi:10.1145/3609502 · Cited by 29 · see citing works
“The impact of these non-clinical inluences on treatment actions and patient responses are further confounded by patient characteristics such as race, gender, or age [9, 10].”
BackgroundBocquier, A., Cortaredona, S., Verdoux, H., Sciortino, V., Nauleau, S., & Verger, P. (2013) · Annals of Epidemiology · doi:10.1016/j.annepidem.2012.12.008 · Cited by 27 · see citing works
“Physicians communicate and treat their patients differently according to their SES [47,48].”
BackgroundDoes socioeconomic status predict outcomes after cholecystectomy?
Ambur, V. V., Taghavi, S., Kadakia, S. S., et al. (2016) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2016.04.012 · Cited by 27 · see citing works
Aloh, H. E., Onwujekwe, O. E., Aloh, O. G., et al. (2020) · BMC Health Services Research · doi:10.1186/s12913-020-05332-0 · Cited by 27 · see citing works
Barnes, K., Ngari, C., Parkurito, S., et al. (2021) · Toxicon X · doi:10.1016/j.toxcx.2021.100078 · Cited by 27 · see citing works
“Evidence from high and upper-middle income settings is that patient factors, including socioeconomic status, attitudes and adherence to treatment, may also influence health workers’ decision making (Hajjaj et al., 2010; Mckinlay et al., 1996; Bernheim et al., 2008).”
BackgroundCavalli‐Björkman, N., Glimelius, B. L. G., & Strang, P. M. (2012) · BMJ Open · doi:10.1136/bmjopen-2012-001248 · Cited by 27 · see citing works
“15 In an American setting, Bernheim showed that clinical decision-making was influenced by patients’ SES but physicians believed this was best for their patients.(16) Recently, attention has been paid to cancer patients who live alone, who tend to present with more advanced disease.”
BackgroundUpdates to Adherence to Hypertension Medications
Roldan, P. C., Ho, G. Y., & Ho, P. M. (2018) · Current Hypertension Reports · doi:10.1007/s11906-018-0830-x · Cited by 27 · see citing works
Chen, C., Weider, K., Konopka, K., & Danis, M. (2014) · Journal of Health Care for the Poor and Underserved · doi:10.1353/hpu.2014.0040 · Cited by 26 · see citing works
Bakens, M. J. A. M., Lemmens, V. E. P. P., & de Hingh, I. H. J. T. (2017) · HPB · doi:10.1016/j.hpb.2017.01.010 · Cited by 26 · see citing works
Social Inequalities in Early Antidepressant Discontinuation
Bocquier, A., Cortaredona, S., Verdoux, H., Casanova, L., Sciortino, V., Nauleau, S., & Verger, P. (2014) · Psychiatric Services · doi:10.1176/appi.ps.201300184 · Cited by 25 · see citing works
Gyasi, R. M., & Phillips, D. R. (2018) · Ageing International · doi:10.1007/s12126-018-9343-9 · Cited by 25 · see citing works
Schuttner, L., Sherlock, S. H., Simons, C. E., Ralston, J. D., Rosland, A.-M. M., Nelson, K. M., Lee, J. R., & Sayre, G. G. (2022) · BMC Family Practice · doi:10.1186/s12875-022-01633-x · Cited by 25 · see citing works
“For example, decisions for these patients must account for disease interactions, conflicting disease recommendations, finite patient capacity for self-management, and impacts from treatment burden [10, 15, 16].”
BackgroundHwang, J., Lyu, B., Ballew, S. H., Coresh, J., Grams, M. E., Couper, D. J., Lutsey, P. L., & Shin, J. (2022) · Journal of the American Geriatrics Society · doi:10.1111/jgs.18165 · Cited by 25 · see citing works
“These findings demonstrated that older adults living with low SES faced greater risk of PIM use with disproportionately higher burden of comorbidities, compared with those with high SES.”
BackgroundInfluentialWill cost transparency in the operating theatre cause surgeons to change their practice?
Glennie, A., Barry, S. P., Alant, J., et al. (2018) · Journal of Clinical Neuroscience · doi:10.1016/j.jocn.2018.09.024 · Cited by 24 · see citing works
Iott, B. E., Pantell, M. S., Adler-Milstein, J., & Gottlieb, L. M. (2022) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocac154 · Cited by 22 · see citing works
Ge, Y., Liang, D., Cao, J., Gosling, R. D., Mushi, V. P., & Huang, J. (2023) · Infectious Diseases of Poverty · doi:10.1186/s40249-023-01075-2 · Cited by 27 · see citing works
“Low SES usually incur personal and financial strains for patients who do seek care [32].”
BackgroundAlfandre, D. (2016) · Journal of Clinical Ethics · doi:10.1086/jce2016271021 · Cited by 17 · see citing works
Hyun, K. K., Brieger, D. B., Woodward, M., Richtering, S. S., & Redfern, J. (2017) · International Journal for Equity in Health · doi:10.1186/s12939-017-0658-z · Cited by 23 · see citing works
“Reasons might include physicians’ clinical management that varies to accommodate patients’ financial status to lessen their burden, as was reported to have been done in primary care [30].”
BackgroundKnowledge, Perception and Attitude Regarding Generic Medicines among Iraqi Physicians
Al‐Jumaili, A. A., Mahdi, L. A., & Kadhim, D. J. (2020) · INNOVATIONS in pharmacy · doi:10.24926/iip.v11i1.2332 · Cited by 22 · see citing works
“In the USA, being aware of patients with low socioeconomic status often influences the management plan of primary care physicians to fit their financial difficulties (28).”
BackgroundHills‐Dunlap, J. L., Melvin, P. R., Graham, D. A., Kashtan, M. A., Anandalwar, S. P., & Rangel, S. J. (2019) · Archives of Pediatrics and Adolescent Medicine · doi:10.1001/jamapediatrics.2019.1061 · Cited by 22 · see citing works
The rich potential for education research in family medicine and general practice
Grierson, L., & Vanstone, M. G. (2020) · Advances in Health Sciences Education · doi:10.1007/s10459-020-09994-7 · Cited by 21 · see citing works
The process of estimating the cost of surgery: Providing a practical framework for surgeons
Christou, C. D., Athanasiadou, E. C., Tooulias, A. I., et al. (2022) · The International Journal of Health Planning and Management · doi:10.1002/hpm.3431 · Cited by 21 · see citing works
Health Disparities Across the Continuum of ASCVD Risk
Devareddy, A., Sarraju, A., & Rodríguez, F. (2022) · Current Cardiology Reports · doi:10.1007/s11886-022-01736-y · Cited by 22 · see citing works
Disparities in Health Care for Minorities: An Ecological Perspective
South-Paul, J. E. (2014) · Springer eBooks · doi:10.1007/978-1-4939-0863-9_14 · Cited by 19 · see citing works
Timbie, J. W., Kranz, A. M., DeYoreo, M., Eshete‐Roesler, B., Elliott, M. N., Escarce, J. J., Totten, M. E., & Damberg, C. L. (2020) · Health Services Research · doi:10.1111/1475-6773.13581 · Cited by 19 · see citing works
Pollack, C. E., Mallya, G. G., & Polsky, D. E. (2008) · Journal of General Internal Medicine · doi:10.1007/s11606-008-0714-x · Cited by 19 · see citing works
“The ways that physicians incorporate patient SES into their decision-making remains poorly understood.(37,38) Our data reveal that physicians’ recommendations for care mirror current SES disparities in actual colorectal cancer screening.”
BackgroundThe effect of socioeconomic factors on patient outcomes in cardiac surgery
McLeish, T., Seadler, B. D., Parrado, R. H., Rein, L., & Joyce, D. L. (2022) · Journal of Cardiac Surgery · doi:10.1111/jocs.17229 · Cited by 18 · see citing works
“Interviews of healthcare providers indicate that a patient's SES influences the clinical decisions they make, and that lower SES is associated with increased personal and financial strain on the healthcare provider and patient.(2) In the case of cardiac diseases, it has been shown that lower SES correlates with higher…”
BackgroundVernazza, C. R., Rousseau, N. S., Steele, J., et al. (2014) · Community Dentistry And Oral Epidemiology · doi:10.1111/cdoe.12129 · Cited by 18 · see citing works
“cians offered patients of lower SES cheaper treatments, seemingly without eliciting patient preferences first (17).”
BackgroundKumar, R., Kumar, K. J., Benegal, V., Roopesh, B. N., & Ravi, G. S. (2019) · Asian Journal of Psychiatry · doi:10.1016/j.ajp.2019.05.006 · Cited by 18 · see citing works
Bærøe, K., & Bringedal, B. H. (2011) · Journal of Medical Ethics · doi:10.1136/jme.2010.042085 · Cited by 18 · see citing works
Omar, M., Soffer, S., Agbareia, R., Bragazzi, N. L., Apakama, D. U., Horowitz, C. R., Charney, A. W., Freeman, R., Kummer, B. R., Glicksberg, B. S., et al. (2024) · medRxiv · doi:10.1101/2024.10.29.24316368 · Cited by 19 · see citing works
Doukky, R., Hayes, K., Frogge, N., et al. (2015) · Clinical Cardiology · doi:10.1002/clc.22382 · Cited by 17 · see citing works
Hire, A. J., & Franklin, B. D. (2024) · BMC Geriatrics · doi:10.1186/s12877-024-04858-w · Cited by 16 · see citing works
“It is known that patients’ SES and insurance status can affect clinical decision making [47, 48], and on prescribing choices made [47].”
BackgroundAndell, P., Li, X., Martinsson, A., Nilsson, P. M., Zöller, B., Smith, J. G., & Sundquist, K. (2020) · International Journal of Cardiology · doi:10.1016/j.ijcard.2020.06.034 · Cited by 15 · see citing works
Chakravarti, T. (2018) · Journal of Ocular Pharmacology and Therapeutics · doi:10.1089/jop.2017.0135 · Cited by 16 · see citing works
Nayak, S. S., Borkar, R., Ghozy, S. A., Agyeman, K. B., Al-Juboori, M. T., Shah, J., & Ulrich, M. T. (2022) · Heart & Lung · doi:10.1016/j.hrtlng.2022.04.017 · Cited by 16 · see citing works
Impact of Area Deprivation Index on Coronary Stent Utilization in a Medicare Nationwide Cohort
Tuliani, T. A., Shenoy, M. H., Parikh, M. G., et al. (2017) · Population Health Management · doi:10.1089/pop.2016.0086 · Cited by 15 · see citing works
“Studies have shown that the socioeconomic status of the patient affects physicians’ clinical decision making.(26) Lowerincome patients with ST elevation myocardial infarction are less likely to receive an angiogram within 24 hours as compared to their higher-income counterparts.”
Women With Coronary Artery Disease
Prata, J., Ramos, S., Martins, A. Q., Rocha‐Gonçalves, F., & Coelho, R. C. (2013) · Cardiology in Review · doi:10.1097/crd.0b013e31829e852b · Cited by 14 · see citing works
“in patients with cAD, social gradient also affects prognosis and mortality,(30) and after an AMi, patients with lower socioeconomic status have a higher risk of experiencing recurrent cardiac events compared with patients with higher socioeconomic status.(31,32) Several authors point to the fact that in women, the soc…”
BackgroundLeach, M., & Segal, L. (2011) · BMC Health Services Research · doi:10.1186/1472-6963-11-221 · Cited by 14 · see citing works
“Given that these biological, psychological and social factors may impact on the best approach to [6], and effectiveness of patient care, neglecting these elements in clinical practice could result in poorer patient outcomes [5].”
BackgroundPongdee, T., Brunner, W. M., Kanuga, M. J., Sussman, J., Wi, C., & Juhn, Y. J. (2023) · The Journal of Allergy and Clinical Immunology In Practice · doi:10.1016/j.jaip.2023.11.030 · Cited by 14 · see citing works
Hernandez, M. I., Miller, E. C., Biese, K. M., Columna, L. A., Andreae, S. J., McGuine, T. A., Snedden, T. R., Eberman, L. E., & Bell, D. R. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph192416709 · Cited by 13 · see citing works
“Physicians accommodate their management plan to suit those with financial difficulties, public/no insurance, and lower health literacy in an attempt to aid low SES patients [4].”
BackgroundMethodResultInfluentialDiko, S., Sheeder, J. L., Guiahi, M., Nacht, A. S., Reeves, S. A., Connell, K. A., & Hurt, K. J. (2020) · International Urogynecology Journal · doi:10.1007/s00192-020-04304-6 · Cited by 13 · see citing works
“, implicit biases) [25], our study suggests that provider expertise in laceration identification may be lower for CNMs who care for underinsured women.”
BackgroundWang, M. D., Jeng-Miller, K. W., Feng, H. L., et al. (2015) · British Journal of Ophthalmology · doi:10.1136/bjophthalmol-2015-307849 · Cited by 13 · see citing works
Is Reporting Race and Ethnicity Essential to Occupational Therapy Evidence?
Breland, H. L., & Ellis, C. (2011) · American Journal of Occupational Therapy · doi:10.5014/ajot.2012.002246 · Cited by 12 · see citing works
Developing Global Competitiveness in Healthcare
Wall, W. P. (2009) · International Journal of Information Systems in the Service Sector · doi:10.4018/jisss.2009062905 · Cited by 12 · see citing works
The influence of sociodemographic factors on operative decision-making in small bowel obstruction
Jean, R. A., Chiu, A. S., O’Neill, K. M., et al. (2018) · Journal of Surgical Research · doi:10.1016/j.jss.2018.02.029 · Cited by 12 · see citing works
Roer, K., Fonager, K., Bingley, P., et al. (2010) · Nordic Journal of Psychiatry · doi:10.3109/08039480903532320 · Cited by 12 · see citing works
Six Recommendations for Provider Behavior Change in Family Planning
Hancock, H., Carlson, O., Hempstone, H., Arnold, B., Hoffmann, K., Gul, X., & Spielman, K. L. (2023) · Global Health Science and Practice · doi:10.9745/ghsp-d-22-00495 · Cited by 12 · see citing works
The Influences of SES on Patient Choice of Doctor: A Systematic Review
Lin, C., Tu, P., Parker, T., Mella-Velazquez, A., Bier, B., & Braund, W. E. (2024) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2024.06.012 · Cited by 12 · see citing works
Afulani, P., Okiring, J., Aborigo, R., Nutor, J., Kuwolamo, I., Dorzie, J. B. K., Semko, S., Okonofua, J., & Mendes, W. (2023) · BMC Health Services Research · doi:10.1186/s12913-023-09261-6 · Cited by 8 · see citing works
“Research with physicians supports this claim, finding that low-SES patients are perceived to be less intelligent, less compliant, and less interested in promoting their own health relative to higher-SES patients [44, 45].”
BackgroundMixed methods evaluation of the Caring for Providers to Improve Patient Experience intervention
Afulani, P. A., Getahun, M., Okiring, J., Ogolla, B. A., Oboke, E. N., Kinyua, J., Oluoch, I., Odiase, O. J., Ochiel, D., Mendes, W. B., et al. (2023) · International Journal of Gynecology & Obstetrics · doi:10.1002/ijgo.15301 · Cited by 8 · see citing works
Biliūnaitė, I., van Gestel, L. C., Hoogendoorn, P., & Adriaanse, M. A. (2024) · Journal of Health Psychology · doi:10.1177/13591053241258205 · Cited by 10 · see citing works
“That is, even though in general HCPs remain slightly more reluctant to recommend apps to lower SES patients (c.f., Bernheim et al., 2008; Dawson et al., 2022), the label does not further increase the digital divide because of differential effects of the label on the likelihood of apps…”
Seif, S., Shah, J., Chandani, A., & Ali, S. K. (2025) · PLoS ONE · doi:10.1371/journal.pone.0322015 · Cited by 12 · see citing works
Nursing students' perceptions of substance abusers: The effect of social status on stigma
Cloyd, M., Stiles, B. L., & Diekhoff, G. M. (2020) · Nurse Education Today · doi:10.1016/j.nedt.2020.104691 · Cited by 10 · see citing works
Pini, T. M., Hawley, S. T., Li, Y., et al. (2012) · Breast Cancer Research and Treatment · doi:10.1007/s10549-012-2116-3 · Cited by 9 · see citing works
“Primary care providers have reported that patient socioeconomic status affects their clinical management decisions including diagnostic testing, medication prescription, and referrals to subspecialists [5,10].”
Olsen, F., Balteskard, L., Uleberg, B., Jacobsen, B. K., Heuch, I., & Møen, A. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-046656 · Cited by 9 · see citing works
Madsen, E. E., Morville, A.-L., Larsen, A. E., et al. (2016) · Scandinavian Journal of Occupational Therapy · doi:10.3109/11038128.2016.1154106 · Cited by 9 · see citing works
“These changes were described as being in the patient’s interest, but in conflict with the standards of care.[5] Other studies describe that patients with low SES received fewer relevant diagnostic examinations and later initiation of therapeutic intervention at the hospitals than patients with high SES.”
BackgroundPsychotropic prescriptions for the treatment of schizophrenia in an outpatient clinic
Okpataku, C. I., & Tawani, D. (2017) · Trends in Psychiatry and Psychotherapy · doi:10.1590/2237-6089-2016-0088 · Cited by 9 · see citing works
Tigges, P., Greser, A., Gágyor, I., Kraft, J., Maun, A., Schmiemann, G., Schwienhorst-Stich, E., Heintze, C., & Schuster, A. (2024) · Frontiers in Public Health · doi:10.3389/fpubh.2024.1383423 · Cited by 9 · see citing works
“This assumption could be rooted in a classist misconception that patients with lower socioeconomic backgrounds may not fully understand the complex Planetary Health implications of antibiotic prescribing (74, 75).”
BackgroundHenry, V., Stephens, M. J., Galyean, P. O., Young, J., Zickmund, S. L., Knettel, B. A., Bartlett, J. A., Watt, M. H., Pollak, K. I., Ubel, P. A., et al. (2023) · International Journal of Radiation Oncology*Biology*Physics · doi:10.1016/j.ijrobp.2023.01.045 · Cited by 8 · see citing works
Brewster, R., Deb, S., Pendharkar, A. V., Ratliff, J. K., Li, G., & Desai, A. M. (2020) · International Journal of Neuroscience · doi:10.1080/00207454.2020.1818742 · Cited by 8 · see citing works
- Authors
- Bernheim, S. M., Ross, J. S., Krumholz, H. M., & Bradley, E. H.
- Affiliations
- Yale University (US)
- James J. Peters VA Medical Center (US)
- Yale New Haven Hospital (US)
- Venue
- The Annals of Family Medicine
- Publisher
- Annals of Family Medicine
- Published
- 2008-01-01
- Volume
- 6
- Issue
- 1
- Pages
- 53-59
- ISSN
- 1544-1709 (ISSN-L)
- 1544-1717
- PMC
- PMC2203396
- OpenAlex
- W1855387788
- Semantic Scholar
- 8ce51f8bdf60034c299b5de71763347bc084a4d1
- Cited by
- 212
- References
- 48
- Citations by year
- 2026: 7 · 2025: 20 · 2024: 20 · 2023: 17 · 2022: 23 · 2021: 11 · 2020: 20 · 2019: 15 · 2018: 7 · 2017: 9 · 2016: 7 · 2015: 6 · 2014: 8 · 2013: 11 · 2012: 5
- FWCI
- 8.97
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Locations
- The Annals of Family Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (submittedVersion)
- PubMed Central (submittedVersion)
- Funders
- National Institute on Aging (T32 AG1934)
- Topics
- Social Sciences › Health › Health disparities and outcomes
- Social Sciences › Health › Public Health and Social Inequalities
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Keywords
- socioeconomic status, clinical management decisions, physician attitudes, primary care physicians, health care inequities, low-income patients, physician stress, patient-centered care, standard of care
- MeSH terms
- Adult, Attitude of Health Personnel, Connecticut, Decision Making, Female, Humans, Interviews as Topic, Male, Medicaid, Middle Aged, Patient Care Management, Practice Patterns, Physicians', Physicians, Family, Quality of Health Care, Social Class, Medically Uninsured, Qualitative Research, Healthcare Disparities
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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