Importance of Communication and Relationships: Addressing Disparities in Hospitalizations for African-American Patients in Academic Primary Care

  • Jessica Valente
  • Natrina Johnson
  • Ugo Edu
  • Leah S. KarlinerEmail author
Original Research



There are many interventions to facilitate seamless continuity of care for patients in transition from hospital back to primary care; however, disparities remain in readmission rates for vulnerable populations, especially African-Americans.


We set out to investigate the association of race and ethnicity with 30-day readmission in our urban academic setting and to identify factors that could be leveraged in primary care to address disparities in hospitalizations.


Using data originally collected for quality improvement purposes, we evaluated 30-day readmission rates for our primary care patients (January 1, 2013–September 30, 2014) by race and ethnicity, adjusting for demographic and clinical characteristics. Then, using inductive and deductive methods, we coded semi-structured interviews with 24 African-American primary care patients who were discharged from the Medicine or Cardiology service at our tertiary care hospital during the study period.

Key Results

African-Americans had the highest readmission rate (21.7%) and a higher adjusted odds of readmission (1.37; 95% CI 1.04–1.81) compared to Whites. Five major themes emerged as having potential to be leveraged in primary care to help prevent multiple hospitalizations: (1) dependable patient-physician relationships, (2) healthcare coordination across settings, (3) continuity with one primary care provider (PCP), (4) disease self-management, and (5) trust in resident physicians. Participants also made several recommendations to keep patients like themselves from returning to the hospital: increased time to tell their story during their primary care visit, more direct patient-physician communication during the visit, and improved access between visits.


While African-American patients in our practice experience higher rates of hospital readmissions than their White counterparts, they emphasize the significance of their PCP relationship and communication to enhance disease management and prevent hospitalizations. Ongoing efforts are needed to establish and implement best practice communication trainings for patients at increased risk of hospitalization, particularly for resident physicians.


communication health disparities qualitative research transitions of care primary care interventions 



Thank you to Jennifer Livaudais-Toman for her assistance with statistical programming.

Funding Information

This work was supported by a grant from the Mount Zion Health Fund.

Compliance with Ethical Standards

The institutional review board at the University of California San Francisco reviewed and granted an exemption for the study.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2019_5392_MOESM1_ESM.docx (21 kb)
ESM 1 (DOCX 21 kb)


  1. 1.
    Jiang JH, Russo A, Barrett M. Nationwide Frequency and Costs of Potentially Preventable Hospitalizations, 2006. 2009. Jiang, H.J. (AHRQ), Russo, C.A. (Thomson Reuters), and Barrett, M.L. (M.L. Barrett, Inc). Nationwide Frequency and Costs of Potentially Preventable Hospitalizations, 2006. HCUP Statistical Brief #72. April 2009. U.S. Agency for Healthcare Research and Quality. Accessed August 27, 2019.
  2. 2.
    Betancourt JR, Tan-McGrory A, Kenst KS. Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries. 2015:1-30. Accessed August 27, 2019
  3. 3.
    Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675-681. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Moy E, Chang E, Barrett M. Potentially preventable hospitalizations - United States, 2001-2009. Morb Mortal Wkly Rep. 2013;62(3):139-143. doi: CrossRefGoogle Scholar
  5. 5.
    Li Y, Cen X, Cai X, Thirukumaran CP, Zhou J, Glance LG. Medicare Advantage Associated With More Racial Disparity Than Traditional Medicare For Hospital Readmissions. Health Aff (Millwood). 2017;36(7):1328-1335. doi: CrossRefPubMedGoogle Scholar
  6. 6.
    Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, D.C.: National Academies Press; 2003.Google Scholar
  7. 7.
    Agency for Healthcare Research and Quality. 2017 National Health Disparities Report. Rockville, MD; 2014. Accessed August 27, 2019.
  8. 8.
    Kripalani S, LeFevre F, Phillips CO, Williams M V., Basaviah P, Baker DW. Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians. Jama. 2007;297(8):831. doi: CrossRefPubMedGoogle Scholar
  9. 9.
    Jones CD, Vu MB, O’Donnell CM, et al. A Failure to Communicate: A Qualitative Exploration of Care Coordination Between Hospitalists and Primary Care Providers Around Patient Hospitalizations. J Gen Intern Med. 2015;30(4):417-424. doi: CrossRefPubMedGoogle Scholar
  10. 10.
    Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital-based physicians and primary care providers with patient outcomes. J Gen Intern Med. 2009;24(3):381-386. doi: CrossRefPubMedGoogle Scholar
  11. 11.
    Lindquist LA, Yamahiro A, Garrett A, Zei C, Feinglass JM. Primary care physician communication at hospital discharge reduces medication discrepancies. J Hosp Med. 2013;8(12):672-677. doi: CrossRefPubMedGoogle Scholar
  12. 12.
    Tang N, Fujimoto J, Karliner L. Evaluation of a Primary Care-Based Post-Discharge Phone Call Program: Keeping the Primary Care Practice at the Center of Post-hospitalization Care Transition. J Gen Intern Med. 2014;29(11):1513-1518. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Sheu L, Fung K, Mourad M, Ranji S, Wu E. We need to talk: Primary care provider communication at discharge in the era of a shared electronic medical record. J Hosp Med. 2015;10(5):307-310. doi: CrossRefPubMedGoogle Scholar
  14. 14.
    Hansen LO, Young RS, Hinami K, Leung A, Williams M V. Interventions to Reduce 30-Day Rehospitalization: A Systematic Review. Ann Intern Med. 2011;155(8):520. doi: CrossRefGoogle Scholar
  15. 15.
    3 M Health Information Systems. 3MTM APR DRG Software 2019. https://www.3 M/en_US/company-us/search/?Ntt = drg + software. Accessed August 27, 2019.
  16. 16.
    Elixhauser A, Steiner C, Harris DR, Coffey RM, Elixhauser A. Measures for Use with Administrative Data Comorbidity. Med Care. 2013;36(1):8-27.CrossRefGoogle Scholar
  17. 17.
    Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury C. Measures of Multimorbidity and Morbidity Burden for Use in Primary Care and Community Settings : A Systematic Review and Guide. Ann Fam Med. 2012;10(2):134-141. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Boyatzis R. Transforming Qualitative Information: Thematic Analysis and Code Development. Thousand Oaks, CA: SAGE Publications; 1998.Google Scholar
  19. 19.
    DeCuir-Gunby JT, Marshall PL, McCulloch AW. Developing and using a codebook for the analysis of interview data: An example from a professional development research project. Field methods. 2011. doi: CrossRefGoogle Scholar
  20. 20.
    Aseltine RH, Sabina A, Barclay G, Graham G, Graham G. Variation in patient-provider communication by patient’s race and ethnicity, provider type, and continuity in and site of care: An analysis of data from the Connecticut Health Care Survey. SAGE open Med. 2016;4:2050312115625162. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Wong MS, Gudzune KA, Bleich SN. Provider communication quality: influence of patients’ weight and race. Patient Educ Couns. 2015;98(4):492-498. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Schoenthaler A, Allegrante JP, Chaplin W, Ogedegbe G. The effect of patient-provider communication on medication adherence in hypertensive black patients: does race concordance matter? Ann Behav Med. 2012;43(3):372-382. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Francis MD, Warm E, Julian KA, et al. Determinants of Patient Satisfaction in Internal Medicine Resident Continuity Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative. J Grad Med Educ. 2014;6(3):470-477. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Street RL, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient Educ Couns. 2009;74(3):295-301. doi: CrossRefGoogle Scholar
  25. 25.
    Harvey, V. M, Ozoemena, U., Paul, J., Beydoun, H. A, Clemetson, N. N, & Okoye, G. A. (2016). Patient-provider communication, concordance, and ratings of care in dermatology: Results of a cross-sectional study. Dermatology Online Journal, 22(11)Google Scholar
  26. 26.
    Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282(6):583-589. Accessed August 27, 2019.CrossRefGoogle Scholar
  27. 27.
    Street RL, O’Malley KJ, Cooper LA, Haidet P. Understanding Concordance in Patient-Physician Relationships: Personal and Ethnic Dimensions of Shared Identity. Ann Fam Med. 2008;6(3):198-205. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Cuevas AG, O’Brien K, Saha S. African American experiences in healthcare: “I always feel like I’m getting skipped over”.” Heal Psychol. 2016;35(9):987-995. doi: CrossRefGoogle Scholar
  29. 29.
    Martin KD, Roter DL, Beach MC, Carson KA, Cooper LA. Physician communication behaviors and trust among black and white patients with hypertension. Med Care. 2013;51(2):151-157. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Street RL, Haidet P. How well do doctors know their patients? Factors affecting physician understanding of patients’ health beliefs. J Gen Intern Med. 2010;26(1):21-27. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Nguyen TT, Vable AM, Glymour MM, Nuru-Jeter A. Trends for Reported Discrimination in Health Care in a National Sample of Older Adults with Chronic Conditions. J Gen Intern Med. 2018;33(3):291-297. doi: CrossRefPubMedGoogle Scholar
  32. 32.
    Sorkin DH, Ngo-Metzger Q, De Alba I. Racial/ethnic discrimination in health care: Impact on perceived quality of care. J Gen Intern Med. 2010;25(5):390-396. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Casagrande SS, Gary TL, Laveist TA, Gaskin DJ, Cooper LA. Perceived discrimination and adherence to medical care in a racially integrated community. J Gen Intern Med. 2007;22(3):389-395. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Tang N, Maselli JH, Gonzales R. Variations in 30-day hospital readmission rates across primary care clinics within a tertiary referral center. J Hosp Med. 2014;9(11):688-694. doi: CrossRefPubMedGoogle Scholar
  35. 35.
    Dang BN, Westbrook RA, Njue SM, Giordano TP. Building trust and rapport early in the new doctor-patient relationship: a longitudinal qualitative study. BMC Med Educ. 2017;17(1):1-10. doi: CrossRefGoogle Scholar
  36. 36.
    Pincavage AT, Lee WW, Beiting KJ, Arora VM. What do patients think about year-end resident continuity clinic handoffs? A qualitative study. J Gen Intern Med. 2013;28(8):999-1007. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Deville C, Hwang W-T, Burgos R, Chapman CH, Both S, Thomas CR. Diversity in Graduate Medical Education in the United States by Race, Ethnicity, and Sex, 2012. JAMA Intern Med. 2015;175(10):1706. doi: CrossRefPubMedGoogle Scholar
  38. 38.
    Xierali IM, Nivet MA. The Racial and Ethnic Composition and Distribution of Primary Care Physicians. J Health Care Poor Underserved. 2018;29(1):556-570. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Betancourt JR, Weissman JS, Kim MK, Park ER, Maina AW. Resident physicains’ preparedness to provide cross-cultural care: Implications for clinical care and medical education policy. Commonwealth Fund. 2007. Accessed August 27, 2019.
  40. 40.
    Weissman JS, Betancourt J, Campbell EG, et al. Resident Physicians’ Preparedness to Provide Cross-Cultural Care. JAMA. 2005;294(9):1058. doi: CrossRefPubMedGoogle Scholar
  41. 41.
    Zickmund SL, Burkitt KH, Gao S, et al. Racial Differences in Satisfaction with VA Health Care: A Mixed Methods Pilot Study. J Racial Ethn Heal disparities. 2015;2(3):317-329. doi: CrossRefGoogle Scholar
  42. 42.
    Sentell TL, Seto TB, Young MM, et al. Pathways to potentially preventable hospitalizations for diabetes and heart failure: A qualitative analysis of patient perspectives. BMC Health Serv Res. 2016;16(1):1-13. doi: CrossRefGoogle Scholar
  43. 43.
    Hoff T, Collinson GE. How Do We Talk about the Physician-Patient Relationship? What the Nonempirical Literature Tells Us. Vol 74.; 2017. doi: CrossRefGoogle Scholar
  44. 44.
    Greysen SR, Harrison JD, Kripalani S, et al. Understanding patient-centred readmission factors: a multi-site, mixed-methods study. BMJ Qual Saf. 2017;26(1):33-41. doi: CrossRefPubMedGoogle Scholar
  45. 45.
    Chang L, Wanner KJ, Kovalsky D, Smith KL, Rhodes K V. “It’s Really Overwhelming”: Patient Perspectives on Care Coordination. J Am Board Fam Med. 2018;31(5):682-690. doi: CrossRefPubMedGoogle Scholar
  46. 46.
    Chew LD, Griffin JM, Partin MR, et al. Validation of Screening Questions for Limited Health Literacy in a Large VA Outpatient Population. J Gen Intern Med. 2008;23(5):561-566. doi: CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Ware J, Kosinski M. SF-36® Physical and Mental Health Summary Scales: A Manual for Users of Version 1. 2nd Editio. Lincoln, RI: QualityMetric, Inc.; 2001.Google Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Jessica Valente
    • 1
  • Natrina Johnson
    • 2
  • Ugo Edu
    • 3
  • Leah S. Karliner
    • 1
    • 4
    Email author
  1. 1.Division of General Internal Medicine University of California San FranciscoSan FranciscoUSA
  2. 2.Department of Health, Law, Policy and ManagementBoston University School of Public HealthBostonUSA
  3. 3.Department of AnthropologyUniversity of California DavisDavisUSA
  4. 4.Multi-Ethnic Health Equity Research Center, Division of General Internal MedicineUniversity of California San FranciscoSan FranciscoUSA

Personalised recommendations