A student's perspective

By Frances Toth and Charles Ellis, PhD, CCC-SLP

Socioeconomic status (SES) is a complex interaction of a wide range of associated factors, such as income, education, insurance status, access to care, and health-related beliefs that have the potential to influence a patient's quality of care.^1-5An extensive literature suggests that SES-related factors have a significant impact on the quality of clinical service provision and associated outcomes.^1,4,5It is possible then that SES has the potential to influence clinical practice patterns in the field of speech-language pathology as well as other clinical disciplines.

Since it is probable that SES indirectly influences clinical practice patterns, the possibility also exists that the specific impact may be influenced by a variety of clinician-related factors. Difficulties can arise from attempts to merge a developing clinical knowledge base, an overwhelming amount of evidenced-based information, and limited clinical experience. These complex factors frequently can be difficult for graduate students to understand adequately the direct and indirect impact on clinical practice patterns even when engaged in mentored clinical experiences. Therefore, graduate student clinicians and less experienced speech-language pathologists, particularly those early in their clinical fellow year (CFY), often are frustrated and disillusioned with the significant impact low SES has on clinical practice patterns.

For example, recent research in the field of medicine has shown that many physicians believe that SES definitely influences how they manage their patients and, subsequently, patient outcomes.²Physicians are forced to prescribe less expensive medications, avoid using specialists, and postpone tests while also trying to accomplish more in one single visit.

Susannah Bernheim, MD, MHS, of Yale University School of Medicine, in New Haven, CT, and colleagues found that some physicians were less aggressive in treating patients with diabetes to accommodate their lack of insurance. SES appears to have a similar influence on practice patterns in speech-language pathology, particularly in regard to the same dilemma related to insurance coverage. Speech-language pathologists often are faced with decreasing the frequency of much-needed visits to allow a greater time period in which to address the communication needs of the patients. Additionally, clinicians may make the decision to see patients for visits of shorter duration to preserve much-needed financial resources.

While the lack of financial resources or—more importantly—the lack of insurance should not impact clinical practice decisions, such factors are often at the forefront of clinical decisions. Evidence-based practice patterns are designed to provide treatment based on the "evidence" and not the availability of insurance coverage. Thus, graduates again are faced with an added factor in the decision-making process.

Interestingly, it is possible that accommodating the SES needs of patients actually can have a negative impact on their outcomes.²It is clear that such decisions have the potential to influence outcomes, however few alternatives are available. Only limited, if any, community-based resources exist that allow individuals with communication disorders to obtain long-term treatments in the absence of insurance. Thus, many are left with long-term deficits that have the potential for improvement if provided with much-needed clinical services.

Other SES-related factors influence clinical outcomes while increasing the burden of caring for patients from low SES backgrounds. Patients from low SES backgrounds are more likely to have difficulties with transportation, which subsequently interferes with attendance or availability for treatment.

Speech-language pathologists are left with some degree of strain related to the necessary changes to the clinical practice patterns to account for issues related to SES. Consequently, some clinicians may be concerned that they are providing lower-quality care, even if a financial-based decision is the only choice for the patient or in the person's best interest.²Graduate students in communication sciences and disorders training programs are challenged to understand the significant impact SES has on clinical practice patterns. Even though these issues are discussed frequently during courses related to clinical management, the true impact typically is not understood clearly until the later stages of clinical training programs, when students are called to take a greater but supervised role in patient management. It appears that additional studies are needed to further examine the interrelationships between SES and evidence-based speech-language pathology practice patterns and to integrate such information into clinical training programs.

References

1. Franks, P., Fiscella, K., Beckett, L., et al. (2003). Effects of patient and physician practice socioeconomic status on the health care of privately insured managed care patients. Medical Care. 41 (7): 842-52.

2. Bernheim, S.M., Ross, J.S., Krumholz, H.M., et al. (2008). Influence of patients' socioeconomic status on clinical management decisions: A qualitative study. Annals of Family Medicine, 6 (1): 53-59.

3. Fiscella, K., Franks, P., Gold, M.R., et al. (2000). Inequalities in racial access to health care. JAMA, 284 (16): 2053.

4. Fiscella, K., Franks, P., Gold, M.R., et al. (2000). Inequality in quality: Addressing socioeconomic, racial, and ethnic disparities in health care. JAMA, 283 (19): 2579.

5. Asch, S.M., Kerr, E.A., Keesey, J., et al. (2006). Who is at greatest risk for receiving poor-quality health care? New England Journal of Medicine, 354 (11): 1147-56.

Frances Toth is a graduate student and Charles Ellis, PhD, is an assistant professor in the Communication Sciences and Disorders Program at the Medical University of South Carolina in Charleston. They can be contacted at tothf@musc.edu and ellisc@musc.edu.