Racial Differences in Physician Recommendation of Hormone Replacement Therapy

Preventive Medicine 33, 668–673 (2001) doi:10.1006/pmed.2001.0943, available online at http://www.idealibrary.com on

Racial Differences in Physician Recommendation of Hormone Replacement Therapy1,2,3 Haoling Holly Weng, M.D., M.H.S.,*,†,4 Colleen M. McBride, Ph.D.,‡ Hayden B. Bosworth, Ph.D.,*,†,‡ Steven C. Grambow, Ph.D.,*,§ Ilene C. Siegler, Ph.D., M.P.H.,‡ and Lori A. Bastian, M.D., M.P.H.*,†,‡ *Center of Health Services Research in Primary Care, Durham VAMC, Durham, North Carolina 27705; and ‡Cancer Prevention, Detection and Control Research, §Division of Biometry, Department of Community and Family Medicine, and †Department of Medicine, Duke University Medical Center, Durham, North Carolina Published online October 24, 2001

Purpose. Previous studies have suggested that black women may be less likely than white women to be offered and to take hormone replacement therapy (HRT). Thus, race and other factors associated with physician recommendation of HRT that may influence women’s decisions about HRT were examined. Methods. Data were from a baseline assessment of participants in a randomized controlled trial designed to evaluate the efficacy of a tailored decision-aid on HRT decision-making. We telephone interviewed 581 Durham women ages 45–54. The association of race and other factors with reported physician recommendation of HRT was tested using ␹ 2 and logistic regression analysis. Results. Overall, 45% of women surveyed reported that their physician recommended HRT; black women were significantly less likely than white women to report being advised about HRT (35% vs 48%, respectively, P ⬍ 0.005). Additional factors associated with being recommended HRT included older age, being postmenopausal, having had a hysterectomy, having thought about the benefits of HRT, and being satisfied with information about HRT.

1 Grant support for this study was received from an American Federation of Aging research grant (H.H.W.), CA72099, and a VA Career Development Award from Health Services Research and Development (L.A.B.). 2 The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veteran Affairs. 3 This work was presented in part at the American Geriatric Society/American Federation of Aging Research annual meeting, Nashville, Tennessee, May 18, 2000. 4 To whom correspondence and reprint requests should be addressed c/o Dr. Lori A. Bastian, Durham VAMC, 508 Fulton Street (152), Durham, NC 27705. Fax: (919) 416-5836. E-mail: basti001@ mc.duke.edu.

Conclusions. Black women are less likely than white women to receive physician recommendation of HRT. Racial differences in patient–provider communication about HRT exist and thus require greater diligence on the part of health care providers to minimize such a gap. 䉷 2001 American Health Foundation and Elsevier Science Key Words: hormone replacement therapy; race; physician recommendation.

INTRODUCTION

Many clinicians regard hormone replacement therapy (HRT) as controversial. The lack of large, controlled, randomized trials to confirm the benefits and risks of HRT contributes to this controversy. Some studies report that HRT improves both quality of life and overall survival [1] as well as decreasing risk for osteoporosis [2], colon cancer [3], and Alzheimer’s disease [4]. Other studies report an increase in risk for heart disease, pulmonary embolus, and breast cancer [5–7]. This conflicting evidence affects physician beliefs about the benefits and risks of HRT [8], which may in turn influence physician counseling and prescribing patterns. Provider recommendation of HRT is one of the most influential factors in determining HRT use among both black [9] and white women [10]. Because most of the HRT studies have included mainly white women [11], providers may be less likely to recommend HRT to black women due to lack of evidence for HRT use among minorities and perceptions that black women are at low risk for osteoporosis. Although the prevalence of osteoporosis is lower among black women compared with white women, age is the most important risk factor for osteoporosis and thus black women are also at risk for fractures as they age. It may be more important to prevent fractures among

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0091-7435/01 $35.00 䉷 2001 by American Health Foundation and Elsevier Science All rights reserved

RACIAL DIFFERENCES IN RECOMMENDATION OF HRT

black women since they experience considerably higher mortality than white women in the first 6 months after a hip fracture [12]. Thus, at this time there is no evidence to suggest that black women have less of a need for HRT compared with white women. Despite the potential benefits of HRT for black women, they are less likely to report having been counseled about HRT and menopause [13], to be satisfied with counseling received about these topics [14], and to be offered HRT [15–17]. Previous studies have documented that rates of HRT use are lower among black women compared with white women [15,18–20]. For example, in a national sample of women ages 45 and older, 14% of the black women had received an estrogen prescription compared with 33% of white women [15]. These studies, however, did not control for other factors that might explain racial differences like sociodemographics, clinical characteristics, knowledge about HRT, and attitudes about menopause. Studying physician recommendations that might differ by race is an important next step in understanding the causes of these differences. Therefore, race and other factors associated with physician recommendation of HRT that may influence women’s decisions about HRT were examined. METHODS

Subjects A community sample of women ages 45–54 were recruited for a randomized controlled trial designed to evaluate the efficacy of a tailored decision-aid intervention on HRT decision-making. Using a purchased list of potentially eligible households, a random sample of women residing in Durham County, North Carolina, were interviewed by telephone during the period between October 1998 and February 1999. Women who did not have a history of breast cancer and were willing to consider information about HRT were eligible. We called 2,388 telephone numbers; 158 (7%) were not in operation, 844 (35%) were ineligible, 444 (18%) were not answered with repeated attempts, and 361 (15%) refused to participate. Among refusers, 93 (26%) answered three eligibility questions and 82 (88%) of these women were eligible for the trial. Of the 860 eligible women contacted by telephone, 581 (68%) agreed to participate. All research received prior approval by the Institutional Review Board of Duke University Medical Center. Measures Women were queried concerning (1) sociodemographics, (2) clinical characteristics, and (3) knowledge and attitudes about HRT. Sociodemographic characteristics included age, race, level of education, marital status,

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adequacy of household income, current health insurance, and regular health care provider. Adequate income was measured on a 4-point scale with 1 ⫽ after paying the bills, the subject still has enough money for special things that she wants, and 4 ⫽ the subject is having difficulty paying the bills, no matter what she does. Clinical characteristics assessed were menopausal status, history of hysterectomy and/or oophorectomy, menopausal symptoms such as hot flashes and night sweats, and presence of comorbidities such as hypertension, diabetes, and blood clots. Menopausal status was dichotomized into postmenopausal and not postmenopausal based on an algorithm [21] that included subject’s perceived menopausal stage, frequency of periods in the past 12 months, and history of oophorectomy. Knowledge and attitudes about HRT included whether the subject thought about benefits of HRT, satisfaction with information about HRT from providers, and the subject’s views of menopause. Women were asked “how much would you say that you have thought about the health benefits associated with HRT for you personally,” on a 0–10 scale with 0 ⫽ not at all and 10 ⫽ a great deal. A similar 0–10 scale was used to measure “how satisfied are you with the amount of information about HRT that your physician/health care provider has given you.” To elicit attitudes about menopause, women were asked whether they agreed that menopause should be viewed as a medical condition. Finally, women were asked, “has a doctor or health care provider ever recommended that you take HRT?” Statistical Analysis The first set of analyses examined whether there were racial differences across the sociodemographics, clinical characteristics, and knowledge and attitudes about HRT variables using ␹2 and t test statistics. ␹2 and t tests were also used to compare whether women who received physician recommendations of HRT differed on these variables. Variables such as whether subjects have thought about the benefits of HRT and satisfaction with information on HRT were dichotomized (above or below median) due to skewed distribution of the responses. We adjusted for multiple comparisons using a Bonferroni adjustment, so that the overall level of significance was 0.01 within each class of comparisons. For multivariate analyses, logistic regression was used to examine factors related to physician recommendation of HRT. To obtain the most parsimonious model, backward selection was used, in which one variable was removed at a time based on the size of the P value. As a variable was removed, the model was refitted with the remaining variables before another variable was removed [22]. Selected interactions were investigated

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after the final reduced model had been identified; however, no significant interactions were observed.

TABLE 1 Characteristics Affecting Physician Recommendation of HRTa

RESULTS

Of the 581 women who were surveyed, 24% (138) were black and 74% (431) were white. Latina, Native American, and Asian women (n ⫽ 7) and those who did not report their race (n ⫽ 5) were excluded. Bivariate Racial Differences Although age, education, and having a regular physician did not differ by race, black women were significantly less likely to be married (61% versus 80%) and to report adequate income (83% versus 92%) compared with white women (P ⬍ 0.01). Black women were significantly more likely to have had a hysterectomy (36% versus 21%) and to have been diagnosed with diabetes (16% versus 5%) and hypertension (35% versus 17%) compared with white women (P ⬍ 0.01). In addition, black women in our cohort were more likely to agree with the view that menopause is a medical condition (85% versus 76%) than white women (P ⬍ 0.01). Black women were not significantly less likely to currently use HRT (23% versus 31%) compared with white women (P ⫽ 0.10). Bivariate Differences in HRT Recommendations Overall, 45% (264) of the women reported that their physician had recommended HRT. Blacks were significantly less likely to report having been recommended HRT (35% versus 48%, P ⬍ 0.005) compared with white women. Those who reported being recommended HRT had a mean age of 50.3 (SD 2.3) years while those who did not report having been recommended HRT had a mean age of 48.8 (SD 2.3) years (P ⬍ 0.001) (Table 1). Recommendation of HRT was significantly associated with current use of HRT (74% versus 45%) compared with those who did not report recommendation of HRT (P ⬍ 0.006). In this cohort of women ages 45–54, other significant factors associated with recommendation for HRT include postmenopausal status, hysterectomy, and menopausal symptoms such as hot flashes and night sweats (P ⬍ 0.001). Having thought about the benefits of HRT was also strongly associated with physician recommendation of HRT (P ⬍ 0.001). Women who were satisfied with information from their provider about HRT (P ⬍ 0.001) were more likely to have been recommended HRT. Multivariate Analyses In the logistic model, after controlling for knowledge and attitudes about HRT, black women remained significantly less likely to report being recommended HRT compared with white women (Table 2). Increasing age

Sociodemographics Mean age (SD) Black Currently married Some college Income is adequate Health insurance Regular health care provider Clinical characteristics Postmenopausal Hysterectomy Bilateral oophorectomy Currently having hot flashes Currently having night sweats Prior diagnosis of diabetes Prior diagnosis of hypertension Prior diagnosis of blood clots Knowledge and attitudes about HRT characteristics Thought about benefits of HRT Satisfied with information about HRT from provider Menopause is medical: strongly agree/ somewhat agree Current HRT user

Physician recommended HRT (n ⫽ 264)

Physician did not recommend HRT (n ⫽ 317)

P value

50.3 (2.3) 18 76 77 91 96

48.8 (2.3) 28 75 75 89 96

0.001 0.005 0.78 0.57 0.35 0.97

95

93

0.25

84 36 20

21 15 6.7

0.001 0.001 0.001

80

50

0.001

69

44

0.001

6.8 20 3.4

9.2 22 2.2

0.3 0.43 0.38

60

18

0.001

47

15

0.001

21 74

22 45

0.77 0.006

a All variables are reported as percentages of the group except for age, which was reported as a continuous variable with a mean and then standard deviation (SD) in parentheses.

was significantly associated with self-reported physician recommendation of HRT. Women who were postmenopausal, had had a hysterectomy, or had thought about the benefits of HRT were significantly more likely to report that a physician recommended HRT. Women who were satisfied with the information given by providers about HRT were significantly more likely to report being recommended HRT. DISCUSSION

In this community-based sample, black women were significantly less likely than white women to report that their physician had recommended HRT. This association remained after adjusting for several important

RACIAL DIFFERENCES IN RECOMMENDATION OF HRT

TABLE 2 Logistic Regression Modeling the Probability of Being Recommended HRT Independent variable Demographics Black Age Clinical characteristics Postmenopausal Hysterectomy Knowledge and attitudes about HRT Thought about benefits of HRT Satisfaction with information about HRT from provider Log likelihood ␹ 2 (df ) c statistic

OR (95% CI) 0.41 (0.23, 0.73) 1.14 (1.03, 1.27) 13.0 (8.0, 21.0) 2.46 (1.41, 4.29) 2.97 (1.84, 4.82) 2.73 (1.68, 4.42) ⫺456.75 336.31 (6) 0.899

Note. OR, odds ratios; CI, confidence interval.

patient factors, such as sociodemographics, clinical variables, and knowledge and attitudes about HRT. Our results are similar to a study of black women (ages 40–49) that was limited by a small sample size [23]. Others also have suggested that black women have knowledge deficits related to menopause and HRT [24] and physicians are not adequately counseling perimenopausal black women about HRT [23,25]. Moreover, it has been argued that the topics of menopause and HRT may best illustrate the disconnect between women’s needs and expectations for information and what is provided by the physician [26], a gap that may be exaggerated for black women. Previous studies have reported significant racial differences in HRT use [23,27]. In the majority of these studies, the number of black women was small and these racial differences were attributed to differential access to health care. In our study, nearly a quarter of the women were black (n ⫽ 138) and we also found that black women were less likely to be using HRT (23% versus 31% for white women). Even after adjustment for sociodemographics such as income and education, we observed significant racial differences in physician recommendation for HRT. Further, health access variables such as whether the subject has health insurance and a regular health care provider also do not significantly affect reported physician recommendation of HRT. Providers may also be bewildered by the various contradictions found in the literature about HRT’s effect on heart disease. However, although HRT’s effect on coronary heart disease is still under debate, HRT’s ability to lower LDL cholesterol [28] has been demonstrated. In general, black women have increased heart disease mortality about a decade earlier than white women [29]. Compared with white women, these relatively young black women in our study have a higher

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prevalence of both diabetes and hypertension and these comorbidities are risk factors for heart disease. Yet, these high rates of diabetes and hypertension are comparable with those found in other studies [30, 31]. It is possible that more comorbidities among black women translate into health care visits that are focused more on these comorbidities and less on topics of prevention such as menopause and HRT. Previously published literature on predominantly white women [32] demonstrated that use of HRT was strongly associated with satisfaction with counseling about HRT as well as a doctor’s recommendation to take HRT. The black women in our study were significantly less satisfied than white women with provider counseling concerning HRT, but in our multivariate model, the racial difference in physician recommendation for HRT remained significant even after adjusting for satisfaction with provider counseling. The conflicting evidence regarding benefits and risks of HRT may add to women’s dissatisfaction with information about HRT. Satisfaction with information about HRT from provider was low among both races (only 32% among blacks and 41% among whites). This desire for information may be representative of women in the Baby Boom Generation because they are better educated, have worked independently outside the home, and, most of all, have greater access to health care information via the Internet [33]. Women may want a greater role in their health care decisions, and many providers are not adequately trained to facilitate this decision-making process. Factors other than race also influenced likelihood of being recommended HRT. Women’s menopausal status was also strongly associated with perceived provider recommendation of HRT. A woman’s perception that she is postmenopausal may lead her to seek remedies from her provider. A provider also may elicit a history of no menstruation for greater than 1 year and thus initiate a dialogue about the benefits and risks of HRT. Age, independent of menopausal status, also was significantly associated with provider recommendation of HRT since older women are more likely to have gone through menopause and have had more opportunities to discuss HRT with their providers. Self-reported physician recommendation of HRT was associated significantly with a history of hysterectomy. Other studies [18,34] have shown that hysterectomy is strongly predictive of HRT use. Having had a hysterectomy may be a proxy for having a gynecologist and since gynecologists tend to recommend HRT more often than internists, women who have had a hysterectomy are more likely to report recommendation of HRT [35,36]. Also, providers may be more likely to recommend HRT to women who have had a hysterectomy because the regimen is less complicated (only estrogen) and does not cause renewed menstruation. Like previous studies

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WENG ET AL. 4. Kawas C, Resnick S, Morrison A, Brookmeyer R, Corrada M, Zonderman A, et al. A prospective study of estrogen replacement therapy and the risk of developing Alzheimer’s disease: the Baltimore Longitudinal Study of Aging. Neurology 1997; 48:1517–21. [Published erratum appears in Neurology 1998; 51:654]

[37], we found that black women are significantly more likely to have had a hysterectomy and therefore may associate menopause as a medical condition. Despite efforts to recruit from the Durham community, our cohort consisted of women who were generally better educated (76% have had some college education) than the general population. A majority (89%) reported adequate income and almost all the women (96%) had some form of health insurance. This may limit generalizability to women who are of lower socioeconomic circumstances. Sociodemographic variables, such as health insurance, were measured at the time of the telephone interview and may have changed since the time of physician discussion, which may have limited results. A further limitation is that our determination of physician recommendation has been based on patient self-report and may not be representative of actual physician prescribing practices. Although this may help explain why current use of HRT does not differ significantly between the two races, current use of HRT only provides a snapshot of HRT use and the duration and pattern of HRT use is complicated by use alternating with disuse. However, we focus on women’s perceptions since provider recommendation of HRT is meaningless unless women actually understand that they have been recommended HRT. Although HRT is not new, information concerning the benefits and risks of HRT is continuously changing, which complicates the decision-making process about HRT. In our study, we found that women who reported that they had thought about the benefits of HRT were more likely to have had physician recommendation of HRT. However, since our analyses were based on crosssectional data, directionality of associations cannot be elucidated. If physicians do not provide information on HRT, women may seek other sources such as the Internet that may not depict the full spectrum of risks and benefits. In conclusion, providers play a key role in helping women make informed decisions about HRT use. Black women rightfully want more information on the risks and benefits of HRT and providers need to bridge this information gap. Providers should strive to clearly communicate the available information and uncertainties, schedule time for the topics of menopause and HRT to be discussed, and furnish more consistent counseling about HRT regardless of race.

10. Ferguson KJ, Hoegh C, Johnson S. Estrogen replacement therapy. A survey of women’s knowledge and attitudes. Arch Intern Med 1989;149:133–6.

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