Caring for African-American Patients in Private Practice
Disparities and Similarities in Dental Procedures and Communication
Kristin A. Williams, DDS, MPH,
Catherine A. Demko, PhD,
James A. Lalumandier, DDS, MPH and
Stephen Wotman, DDS
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ABSTRACT
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Objective. Disparities in oral health care among racial and low socioeconomic groups have been reported. The authors compared the communication behaviors and dental services to African-American and white patients in private dental offices.
Methods and Subjects. The investigators directly observed office visits of 292 black and 1,552 white patients in 64 practices by using standardized checklists for the frequency of services provided and frequency and time of communication behaviors. From patient surveys, they constructed three communication scales and a patient satisfaction score. They examined the effects of provider-patient racial concordance on dental services and observed and perceived communication behaviors by using multiple regression analyses.
Results. Groups of black and white patients had similar demographic characteristics. Dental procedures were similar for black and white patients in offices with white providers. Compared with white patients, black patients with white providers reported lower ratings for how well the dentist knew them (P = .001), but patients’ satisfaction with their providers was high and not affected by provider-patient racial concordance. After multivariate adjustment, odds of chatting were significantly lower between black patients and white providers than between racially concordant patients and providers (odds ratio = 0.38; P < .001), whereas odds of negotiation were lower among black patients regardless of the race of the provider.
Conclusions. In this study sample, the investigators did not observe overt disparities in dental services on the basis of race. They noted that some communication behaviors were influenced by dentist-patient racial concordance, which suggests the possibility of more subtle disparities than usually are considered.
Clinical Implications. Dental professionals could benefit from understanding their patients’ perceptions of a range of interactions that occur during a typical dental visit.
Key Words: African-Americans; dental care; dental private practice; dentist-patient relations; office visits; communication; racial disparitiesAbbreviations: DOC: Davis Observation Code. • DOS: Direct Observation Study of Dental Practice. • VA: Veterans Affairs.
The Institute of Medicine report "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care"1 provides several key findings and recommendations concerning medical care in the United States. These findings state that "racial and ethnic minorities tend to receive a lower-quality of health care than non-minorities, even when access-related factors, such as patients’ insurance status and income are controlled."1(p1) This statement is supported by findings from studies focused on racial variation in cardiac procedures2 and colorectal surgery.3 Investigators4 also have considered socioeconomic, racial and ethnic disparities in quality of care.
In the dental literature, investigators have documented racial and economic disparities regarding the level of dental disease,5 dentist’s decision making6 and effects of dental practice characteristics.7 Investigators also have reported health disparities associated with racial variation within the Department of Veterans Affairs (VA) health care system,8 a dental school clinic9 and a prospective community-based study in Florida (the Florida Dental Care Study).10 These studies focused on populations with socioeconomic deprivation along with racial variation, and their results support the premise that dental service disparities, like medical care disparities, occur generally among underserved populations. An examination of racial disparities in oral health care among patients in private dental practice requires a different sample of providers and patients from those studied previously.
The medical literature is extensive concerning both the cultural competence of practitioners and patients’ perceptions of cultural sensitivity while receiving care.11,12 Cultural competence affects not only patient-provider interactions but also patients’ comfort and health outcomes. Investigators13–15 have measured patients’ satisfaction in family medical practices and satisfaction related to patients’ interpersonal interactions with their physicians. When racial concordance exists between patient and provider, patient satisfaction increases, which can lead to improved health outcomes. The combination of patients’ comfort with practitioners and satisfaction with care also may yield long-term effects on oral health, although results of such studies have not yet been reported in the dental literature.
An examination of racial disparities in oral health care among patients in private dental practice requires a different sample of providers and patients from those studied previously.
This implementation of the multimethod Direct Observation Study of Dental Practice16 (DOS) in a practice-based dental research network in northern Ohio provided us with the opportunity to investigate one facet of the issue of disparities in health care. We sought to determine whether differences exist in services provided to white and African-American patients receiving care in the same set of private dental offices and whether these differences extend to issues of dentist-patient communication. We hypothesized that differences in services, as well as observed and perceived communication levels among white and black patients, may be associated with racial concordance between patient and provider.
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METHODS AND SUBJECTS
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Direct observation study.
The Community Research for Oral Wellness Network was formed in 199816 and expanded in 2004 with funding for the DOS. Our purpose in this study was to measure, by using multiple methods, the content and context of patient-provider interactions for both dentists and hygienists with a focus on the delivery of preventive services. Study methods were described in a previous publication.17 Briefly, we invited 2,500 private dental offices across northern Ohio to participate; we enrolled 120 of 166 responding offices from rural, urban and suburban locations, which we selected on the basis of power calculations to test the main hypotheses of the overall study. Teams of trained observers (research hygienists) visited each of these offices for three days of direct observation and one day of chart abstraction between June 2004 and September 2005. Hygienist-observers positioned themselves unobtrusively in the dental operatory so that they could see and hear visit interactions but could not participate in any way. We minimized observer variability by means of intense training and repeated standardization by using videotapes of routine dental encounters in practice situations. For interrater reliability of direct observation, we calculated multirater 
coefficients for procedures and communication behaviors, which ranged from 0.69 (good) to 0.92 (excellent).17
Using direct observation, we captured the behaviors of dentists and hygienists during patient visits using the Dental Davis Observation Code (DOC). The Dental DOC is a modified version of the medically oriented DOC, which prompts the recording of 24 observed practitioner behaviors at 30-second intervals.18 Observers also recorded the occurrence of specific dental procedures using a predefined list of 65 common dental procedures. The self-administered surveys completed by dentists and hygienists collected demographic data (age, race, sex and years in practice). Patient surveys included demographic information and 15 items measuring communication with the provider and overall satisfaction with the visit. A national advisory committee consisting of experts in health services research reviewed the study methodology, and the Case Western Reserve University Institutional Review Board approved the study.
Observed study measures.
We analyzed the occurrence of six common dental procedures: extractions, placement of amalgam restorations, placement of composite restorations, crown and bridge procedures, endodontic procedures and preventive procedures (excluding prophylaxis).
Measures of observed communication included chatting, negotiation and patients’ questions, which the research hygienists recorded every 30 seconds on the Dental DOC for the entire provider-patient contact time (see definitions in Table 1
). We calculated the percentage of visits and the mean number of intervals in which the research hygienists observed the codes.
Self-reported study measures of perceived communication.
Measures of provider-patient communication also included patients’ perceptions as reported on the patient survey; these data were available for the 1,461 white and 273 black patients who completed a questionnaire after the dental visit. We adapted the DOS survey questions that a family medicine group originally validated for a primary care network study.19 We conducted a factor analysis of 13 survey items on the full DOS data set by using a principal-components analysis with a varimax rotation.20,21 We used a five-point Likert scale (1 = strongly disagree, 5 = strongly agree) for all item responses. The analysis generated three communication sub-scales named "provider knows me," "continuity of care" and "rapport." These three factors accounted for 70.1 percent of the variance, and each factor scale demonstrated high internal reliability (Cronbach 
, 0.83, 0.83 and 0.91, respectively). Table 2 lists the items included in each factor scale. We averaged patients’ responses for each scale. In addition, two items measured patients’ satisfaction with the provider: "Overall, I was satisfied with my visit to the dentist/hygienist today" and "I would send my family/friends to this dentist/hygienist." We combined these items to calculate the satisfaction scale.
Patient groups and outcome.
For this analysis, we categorized patients into three groups on the basis of their self-reported race and the race of their provider: white patients observed in practices operated by white dentists (group 1), black patients observed in practices operated by the same white dentists as in group 1 (group 2) and black patients observed in practices operated by black dentists (group 3). We excluded eight white patients in practices with black providers from further analysis, as the numbers were too few for meaningful comparisons.
Patients’ self-reports of rapport and satisfaction with their dentists were high, and the racial concordance of dentist and patient did not factor significantly into these outcomes.
Analysis.
We used STATA 8.0 (Stata, College Station, Texas) to conduct all analyses by using the cluster option to account for the non-independent effect of patients within offices and to calculate robust variance estimates. We analyzed differences in prevalence of dental procedures and observed communication (via the dental DOC) among patient-provider groups by performing 
2 tests of independence, which were reported as design-based F statistics from the clustered analysis. We compared perceived communication scales (provider knows me, continuity of care, rapport) among the three groups by using a one-way analysis of variance and the Kruskal-Wallis test for satisfaction, followed by post hoc analysis, when we found the global test results to be significant. We modeled predictors for perceived communication scales and observed dichotomous communication codes by using multiple linear regression and logistic regression analysis, respectively. We adjusted the final models for patient’s age, sex, income, education, status in practice, visit length and self-reported oral health. Patients reported their education and income levels, and we included these data as categorical variables in the regression models. The percentage of nonresponse for self-reported income was essentially the same among white patients (259 of 1,552, 16.7 percent) as among black patients (50 of 292, 17.1 percent). We imputed missing income categories by using the STATA impute command on the basis of age, sex, race, education and insurance status. Because the satisfaction score exhibited a ceiling effect (that is, most patients were very satisfied with their provider), we modeled the score in several ways but found no difference in the results. For ease of interpretation, we generated predicted scale means from adjusted regression models for comparison with unadjusted means; we determined odds ratios with 95 percent confidence intervals from the logistic models. We considered a P value 
.05 as statistically significant.
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RESULTS
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A total of 292 self-identified black patients received care in 64 of the 120 observed practices. Five of these practices, operated by black dentists, served 109 black patients. The other 59 practices, operated by white dentists, provided care for 183 black patients and 1,552 white patients during the three-day observation period. On average, these practices saw three black patients (range, 1–18).
Characteristics of patients.
Table 3 shows patient and visit characteristics. Patients in the three groups were similar according to age, sex, education and perceptions of oral and general health. The distribution in educational levels confirms that this was a well-educated sample of patients, regardless of race. In contrast, black and white patients were distributed differently between the two upper income levels, but there was little difference in the proportion at the lowest level. Black patients seen in these private offices were more likely than the white patients to have any insurance. The three groups had similar proportions of new patients, but group 2 (black patients with white providers) had the lowest proportion of patients in the practice for three or more years. There were no differences in visit length or the proportion of patients with dental and hygiene appointments among the groups.
Directly observed procedures and communication.
The three groups did not differ significantly in frequencies of extractions, amalgam and composite restorations, endodontic treatment and preventive procedures (Figure). The black patients in practices with black providers received significantly fewer crown or bridge treatments than did patients in other practices (design-based F = 10.2; P < .001).
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Figure. Percentage of visits with observed dental procedures compared according to groups (group 1, white providers with white patients; group 2, white providers with black patients; group 3, black providers with black patients). Only the provision of crown or bridge procedures was different among the three groups, occurring least often in group 3 (P < .001).
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For observed communication, frequency of both chatting and negotiation were different among the three groups. Chatting occurred least often between white providers and black patients (90.7 percent of visits; groupwise design-based F = 8.8; P < .001), whereas negotiation occurred most frequently between white patients and white providers (19.5 percent) compared with findings in the other groups (groupwise design-based F = 4.5; P = .013) (Table 4). Our research hygienists observed patients asking questions at similar frequencies in all three groups. After adjusting for patient and visit characteristics in the logistic regression analysis, we confirmed that black patients had lower odds of chatting with white providers compared with white patients chatting with white providers, whereas negotiation was significantly lower among black patients compared with white patients, regardless of the race of the provider. We did not observe that racial concordance affected the frequency of patients’ questions.
An observed estimate of the number of 30-second intervals spent by dentists on communication revealed fewer intervals of chatting between white providers and black patients (8.7 intervals ± 9.6) compared with intervals in racially concordant groups 1 and 3 (Table 5). Although observed to occur less frequently, negotiating care decisions occurred in slightly more intervals (that is, more time) between black patients and white providers (2.5 intervals ± 2.0) compared with intervals in the racially concordant groups 1 and 3. Time spent on patients’ questions among the groups was not significantly different.
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TABLE 5 Number of observed 30-second intervals of communication behaviors between dentist and patient, according to group.
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Perceived communication analysis.
In addition to observed procedures and communication behaviors performed by dentists, we examined the patients’ perceptions of the dentist’s communication and their overall satisfaction with their dental care experiences. Table 6 shows the unadjusted means of the communication scales for each group. For the first two scales, "provider knows me" and "continuity of care," black patients in the offices with white providers (group 2) had the lowest scores, suggesting that these patients perceived that their dentists knew them less well and placed less importance on continued care from one dentist compared with white patients in the same office. In contrast, perceived rapport and self-reported satisfaction were similar across the groups.
To account for the effect of other factors on the perceived communication outcomes, we constructed multiple linear regression models for each scale (Table 6
). We entered patients’ socio-demographic variables, self-reported oral health status, patients’ status in practice and visit length as baseline predictors, followed by the addition of the variable identifying the dentist-patient racial concordance (groups 1–3 in adjusted model). Baseline models accounted for modest amounts of the variance (3.8–15.4 percent, data not shown). In the final adjusted model, the variable for dentist-patient racial concordance remained a significant but modest predictor for "provider knows me" and "continuity of care" and marginally improved the explained model variance. The racial concordance variable remained nonsignificant for rapport and satisfaction in this data set.
In summary, the full model predicted only a modest amount of variance in patients’ perceived communication. Racial concordance remained an independent predictor of how well patients believed their dentists knew them and the importance of continued care by their dentists as well as for the observed interpersonal behaviors of chatting and negotiation. Patients’ self-reports of rapport and satisfaction with their dentists were high, and the racial concordance of dentist and patient did not factor significantly into these outcomes.
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DISCUSSION
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Our research hygienists observed black patients in one-half of the Ohio practices participating in the DOS; these patients composed approximately 8 percent of the total patient sample. In general, white dentists treating these patients provided the same frequency and distribution of procedures to their black patients as they did to their white patients. This finding suggests that the black patients in these offices do not experience a disparity in dental care, as others have reported in the literature.7–9,22 We noted that directly observed (chatting and negotiation) and patient-perceived ("provider knows me" and "continuity of care") communication behaviors were influenced significantly in this data set by dentist-patient racial concordance, but overall rapport and satisfaction were not different among these groups. These findings suggest the possibility of more subtle differences in the health care interactions between black patients and white dentists, although, importantly, delivered care and patient satisfaction did not appear to be affected.
This study’s findings vary from those of previous studies demonstrating disparities in dental care delivery to black patients, most likely because of differences in this study’s population compared with those of previous studies. For example, Gilbert and colleagues5 reported care disparities in several articles from the Florida Dental Care Study, in which investigators used a sampling technique to identify dentate people 45 years or older from the general Florida population and to oversample blacks, people with low incomes and residents of nonmetropolitan counties. In that study, 77 percent of black participants had an eighth-grade education or less, 63 percent had annual incomes below 100 percent of the poverty level, and only 32 percent had dental insurance. The patients’ dentists reported the oral health information. In contrast, our study started with a defined group of private practices, thereby allowing comparison of services in different patient groups from similar environments. Kressin and colleagues8 reported racial variation in dental procedures focusing on endodontic therapy versus tooth extraction for patients at a VA facility. VA facilities treat a wide variety of patients, but more affluent patients tend to remain in the general health care system. Most recently, Okunseri and colleagues9 reported racial and ethnic variation in the provision of dental procedures in the dental clinics of Marquette University in Milwaukee. Black patients composed 20 percent of the population included in that study. Only 11 to 17 percent of the black patients had annual incomes above the poverty level, and 4 to 7 percent had private dental insurance. The lack of disparity in procedures provided to black patients in the DOS may be due to the fact that its patient groups are more demographically similar than are those in previous studies. Black patients who sought care in these private dental practices underwent similar dental procedures as did white patients. This finding offers support to the idea that disparities depend on economic status as well as race.23
We identified a difference in patients’ perceptions of interactions with their providers that had a modest relation to patient-provider racial concordance. The findings suggest that black patients in practices with white providers perceive that their providers know them less well compared with the finding in white patients in the same practices and that these black patients place less importance on continuing care with one provider. Although we have no evidence that the providers actually knew these patients less well, the attitudes that patients form about their health care providers potentially can influence their attitudes and behaviors toward seeking care and complying with care and treatment recommendations. Similar findings in medicine demonstrated that cultural competence in communicating with diverse patient populations influenced patients’ comfort levels in seeking care.11,12 Whether a similar situation exists in dental care is not yet known but deserves attention. Importantly, we detected no significant differences in patients’ satisfaction or perceptions of rapport. Thus, the clinical importance of the small perceived deficits in communication remains to be determined. Because patients’ attitudes likely reflect an accumulation of interactions beyond one observed visit, future studies should expand and refine the patient questions to explore in greater detail the formation of these perceptions.
Important limitations and several unusual strengths exist in this data set focusing on the delivery of services to black patients. We restricted the analysis to practices in which we observed a black patient during the three-day observation, even though other practices may care for black patients. Our ability to generalize our data about care practices by dentists of any racial minority also is limited because we observed only five offices with a black provider, so the focus of our comparison remained at the patient level and the racial concordance group to which the patient belonged. Even with all measured predictors in the models, the percentage of variance explained was not high, suggesting that we did not collect all the optimal predictors needed to determine these communication outcomes and satisfaction. Finally, we did not measure directly the care needed in any of the three patient groups, so we must rely on the similarities of the patient characteristics among the groups to presume that the patients’ dental needs were comparable. Black patients received fewer crown or bridge services from black dentists compared with both black and white patients who had white dentists. One explanation may be a difference in the care needed, requested or accepted by these patients.24
Despite these limitations, the measurement of service delivery and dentist-patient interactions by means of direct observation has not been performed previously and provides a unique contribution to understanding the role of racial concordance in dental care. Although the direct observation method has potential limitations, we made available the specific aims of our study to the practitioners only in general terms, and the time constraints of daily routine made it difficult for practitioners to alter their behaviors substantially.25 The observers were hygienists who were trained to use general terms when answering questions about the study from office personnel. At the end of data collection, we gave the participating dentists the results from their practices and have had the opportunity to discuss the findings with them.
This is the first study of which we are aware in which the investigators examined practitioners’ communication behaviors and patients’ perceptions of communication at the same time that they evaluated the procedures to determine disparities of care. It is unknown whether these differences between black and white patients and their providers in terms of communication and patients’ perceptions affect compliance or oral health outcomes. It would seem that dentists would want to do whatever they can to ensure that patients are comfortable with their care and continue to seek regular dental care. These findings may suggest that raising awareness levels of cultural sensitivity might be useful for practitioners,26 as well as for dental students.
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CONCLUSION
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Black patients in private dental practices in northern Ohio receive dental procedures with similar frequencies as their white counterparts, suggesting that there are no overt disparities in dental care provided to these patients. However, we measured subtle differences in communication between racially concordant and discordant patient-provider interactions. Replication and further exploration of these findings in other dental cohorts are needed.
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FOOTNOTES
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Dr. Williams is an assistant professor, Department of Community Dentistry, School of Dental Medicine, Case Western Reserve University, 10900 Euclid Ave., Cleveland, Ohio 44106, e-mail "kristin.williams{at}case.edu". Address reprint requests to Dr. Williams.
Dr. Demko is an assistant professor, Department of Community Dentistry, School of Dental Medicine, Case Western Reserve University, Cleveland.
Dr. Lalumandier is an associate professor and chair, Department of Community Dentistry, School of Dental Medicine, Case Western Reserve University, Cleveland.
Dr. Wotman is a professor, Department of Community Dentistry, School of Dental Medicine, Case Western Reserve University, Cleveland.
Disclosure. None of the authors reported any disclosures.
This work was supported by National Institutes of Health/National Institute of Dental and Craniofacial Research (NIH/NIDCR) grant and minority supplement R01DE015171.
The authors thank the following people for their contributions to this study: Kristin Z. Victoroff, DDS, PhD; Joseph Sudano, PhD; observers Marian Kofford, Kate Mingus, RDH, Gail Perry, RDH, Marlene Rodriguez, RDH, Marianne Scherry, RDH, Becky Slivka and Joy Wiedemann; the National Advisory Committee, consisting of Howard Bailit, DDS, PhD, Duncan Neuhauser, PhD, Edward Callahan, PhD, Randall Cebul, MD, PhD, Benjamin Crabtree, PhD, Donna Homenko, RDH, PhD, Kurt Stange, MD, PhD, and Stephen Zyzanski, PhD; and the dentists, hygienists, personnel and patients of the 120 practices who graciously allowed us to observe them in action.
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REFERENCES
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- Smedley BD, Stith AY, Nelson ER, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington: National Academy Press; 2003.
- Peterson ED, Wright SM, Daley J, Thibault GE. Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs. JAMA 1994;271(15): 1175–1180.[Abstract/Free Full Text]
- Ellison GL, Warren JL, Knopf KB, Brown ML. Racial differences in the receipt of bowel surveillance following potentially curative colorectal cancer surgery. Health Serv Res 2003;38(6 pt 2):1885–1903.[Medline]
- Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA 2000;283(19):2579–2584.[Abstract/Free Full Text]
- Gilbert GH, Shah GR, Shelton BJ, Heft MW, Bradford EH Jr, Chavers LS. Racial differences in predictors of dental care use. Health Serv Res 2002;37(6):1487–1507.[Medline]
- Cabral ED, Caldas Ade F Jr, Cabral HA. Influence of the patient’s race on the dentist’s decision to extract or retain a decayed tooth. Community Dent Oral Epidemiol 2005;33(6):461–466.[Medline]
- Gilbert GH, Shewchuk, RM, Litaker MS. Effect of dental practice characteristics on racial disparities in patient-specific tooth loss. Med Care 2006;44(5):414–420.[Medline]
- Kressin NR, Boehmer U, Berlowitz D, Christiansen CL, Pitman A, Jones JA. Racial variations in dental procedures: the case of root canal therapy versus tooth extraction. Med Care 2003;41(11):1256–1261.[Medline]
- Okunseri C, Bajorunaite R, Matthew R, Iacopino AM. Racial and ethnic variation in the provision of dental procedures. J Public Health Dent 2007;67(1):20–27.[Medline]
- Gilbert GH, Duncan RP, Vogel WB. Determinants of dental care use in dentate adults: six-monthly use during a 24-month period in the Florida Dental Care Study. Soc Sci Med 1998;47(6):727–737.[Medline]
- Betancourt JR, Reid AE. Black physicians’ experience with race: should we be surprised? Ann Intern Med 2007;146(1):68–69.[Free Full Text]
- Weissman JS, Betancourt J, Campbell EG, et al. Resident physicians’ preparedness to provide cross-cultural care. JAMA 2005;294(9): 1058–1067.[Abstract/Free Full Text]
- Chen FM, Fryer GE Jr, Phillips RL Jr, Wilson E, Pathman DE. Patients’ beliefs about racism, preferences for physician race, and satisfaction with care. Ann Fam Med 2005;3(2):138–143.[Abstract/Free Full Text]
- Eiser AR, Ellis G. Viewpoint: cultural competence and the African American experience with health care—the case for specific content in cross-cultural education. Acad Med 2007;82(2):176–183.[Medline]
- Laveist TA, Nuru-Jeter A. Is doctor-patient race concordance associated with greater satisfaction with care? J Health Soc Behav 2002;43(3):296–306.[Medline]
- Wotman S, Lalumandier J, Nelson S, Stange K. Implications for dental education of a dental school-initiated practice research network. J Dent Educ 2001;65(8):751–759.[Abstract]
- Demko CA, Victoroff KZ, Wotman S. Concordance of chart and billing data with direct observation in dental practice. Community Dent Oral Epidemiol. "www3.interscience.wiley.com/journal/120122021/issue".Published Nov. 28, 2007. Accessed July 31, 2008.
- Callahan EJ, Bertakis KD. Development and validation of the Davis Observation Code. Fam Med 1991;23(1):19–24.[Medline]
- Flocke SA. Measuring attributes of primary care: development of a new instrument. J Fam Pract 1997;45(1):64–74.[Medline]
- Kim J, Mueller CW. Introduction to Factor Analysis: What It Is and How To Do It. Beverly Hills, Calif.: Sage; 1978.
- SPSS 12.0 Command Syntax Reference Manual. Vol. 1. Chicago: SPSS; 2004.
- Manski RJ, Moeller JF. Use of dental services: an analysis of visits, procedures and providers, 1996. JADA 2002;133(2):167–175.[Abstract/Free Full Text]
- Chung KD. African-American health disparities: a literature review of the determinants. J Assoc Acad Minor Phys 2003;14(2/3): 30–38.
- Tilashalski KR, Gilbert GH, Boykin MJ, Litaker MS. Racial differences in treatment preferences: oral health as an example. J Eval Clin Pract 2007;13(1):102–108.[Medline]
- Stange KC, Zyzanski SJ, Smith TF, et al. How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patient visits. Med Care 1998;36(6):851–867.[Medline]
- Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med 2004;19(2):101–110.[Medline]
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ABSTRACT
METHODS AND SUBJECTS
