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Table 2 Included studies – descriptive characteristics and main findings

From: The use of experimental vignette studies to identify drivers of variations in the delivery of health care: a scoping review

Study

Research question

Geographical setting

Healthcare setting

Participants

Process or decision

Patient characteristics

Possible drivers of variation

Condition

Findings

Adams et al, 2014 [53]

Identification of mechanisms driving differential diagnoses and disparities that are common to black and white people in both countries; examination ofbetween-country variations due to cultural and health care system differences

UK and USA

Primary care

Physician

Diagnosis, referral, prescription

Ethnicity (black, white)

Information processing, patient cues, knowledge used, healthcare system.

Depression

There was little bias in doctors' decisions overall. UK doctors had greater clinical uncertainty in diagnosing depression amongst black than white patients . Doctors focused more on black patients' physical than psychological symptoms and more often tended to identify endocrine problems.

Begeer et al, 2008 [54]

Whether ethnic background influences the likelihood of pediatricians’ references to Autism when using clinical judgments versus ratings of explicit diagnostic categories

Netherlands

Child health setting

Physician

Diagnosis

Ethnicity (Dutch vs Moroccan or Turkish)

Spontaneous vs prompted likelihood; physician characteristics

Autism

Spontaneous clinical judgements resulted in ethnic bias; this bias disappeared when doctors were prompted to consider autism.

Bernardes et al, 2013 [55]

Whether physician sex moderates the effects of patient (distressed) pain behaviours and diagnostic evidence of pathology on treatment prescriptions and referrals; explore the mediating role of pain credibility judgments and psychological attributions on these effects

Portugal

Primary care

Physician

Referral, prescription, assessment

Gender

Physician sex, clinical cues (evidence of pathology, distress)

Chronic lower back pain

Confirming the hypothesis, physician sex moderates the influence of clinical cues on pain management practices: evidence of pathology had a larger effect on male than on female physicians’ referrals to psychology/psychiatry.

Bories et al, 2018 [56]

To test the hypothesis that physician uncertainty aversion impacts medical decision making for older patients with acute myeloid leukaemia

France

Acute

Physician

Prescription

Age (note clinically relevant)

Physician demographic, occupational, behavioural characteristics

Acute myeloid leukaemia

Physician attitudes to risk influenced chemotherapy decisions for older patients. Physicians opting for intensive chemotherapy (IC) had higher aversion to uncertainty and treated fewer patients annually, than the low IC group but were similar in age, hierarchical status or years of experience.

Burgess et al, 2014 [57]

To test the hypothesis that racial biases in opioid prescribing would be more likely under high levels of cognitive load

USA

Primary care

Physician

Prescription

Ethnicity (black, white)

Physician cognitive load

Chronic low back pain

Hypotheses were partially confirmed. Cognitive load altered ethnic inequalities in prescribing patterns in different ways for male and female physicians. Under high cognitive load, male physicians were more likely to prescribe opioids for White patients; while under low cognitive load, they were more likely to prescribe opioids for Black patients. Female physicians’ bias toward prescribing opioids to Black patients was stronger under greater cognitive load.

Burt et al, 2016 [58]

To examine whether South Asian people rate GP consultations similarly to White British people, in order to understand why minority ethnic groups often give poorer evaluations of primary care

England

Primary care

Public

Consultation style

Ethnicity (South Asian, white)

Patients' ratings of quality

Persistent cough, perforated ear drum, painful elbow generalised numbness

Respondents from a Pakistani background rated communication in simulated GP consultations significantly more positively than their White British counterparts (contrary to the hypothesis that South Asians’ poorer evaluations of primary care experience is due to higher expectations of care).

Daugherty et al, 2017 [59]

To test the hypotheses that physician gender bias would have little effect on treatment decisions for the male patient and would result in lower use of cardiovascular tests among gender-biased physicians for female patients

USA

 

Physician

Diagnosis

Gender

Implicit bias

Coronary artery disease

Hypotheses were partially confirmed; cardiologists who associated risk taking more with men than with women were more likely to view angiography as useful to diagnose male versus female patients but equally likely to recommend stress testing. Physicians were less certain of diagnosis in women than men.

Elliott et al, 2016 [60]

To test whether hospital-based physicians use different verbal and/or nonverbal communication with black and white simulated patients and their surrogates.

USA

Acute

Physician

Consultation style

Ethnicity (black, white)

Verbal and non-verbal communication between patient & physician

Metastatic gastric and pancreatic cancer

Physicians used similar verbal but different nonverbal communication behaviours with black and white patients.

Fischer et al, 2017 [61]

To test whether patient requests for specific opioid pain medication would lead physicians to classify them as drug-seeking and change management decisions

USA

Primary care

Physician

Prescription

Ethnicity (black, white)

Patient (drug seeking) behaviour

Pain (sciatica)

Physician suspicion of drug-seeking behaviour was much higher when patients requested opioid medication. Physician suspicion of drug-seeking behaviour did not vary by patient characteristics, including gender and race.

Gao et al, 2019 [62]

To test whether Chinese favour family-centred decision making while European Americans favour shared decision making in depression care

USA

Other - mental health

Public

Mode of decision making - hospital or community care

Race, nationality

Acculturation, preferences for care

Depression

Hypotheses were confirmed; Chinese preferred family-centred decision making while Americans preferred shared decision making. Chinese living in America paralleled European Americans.

Green et al, 2007 [63]

To test whether implicit or explicit race biases predict physicians' decisions to give thrombolysis for acute myocardial infarction

USA

Acute and primary care

Physician

Diagnosis, prescription

Ethnicity (black, white)

Physician implicit bias

Acute myocardial infarction

Hypothesis was confirmed. As physicians’ pro-white implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis.

Hirsh et al, 2009 [64]

To test whether gendered expectations of pain and facial pain expressions influenced pain assessment and treatment disparities in nurses

USA

Acute

Nurse

Prescription

Age, sex, race

Gender role expectations of pain (sensitivity, endurance, willingness to report), high/low pain facial expression

Pain appendectomy

Hypotheses were partially confirmed; nurses’ gender role expectations of pain didn’t influence decisions but pain expression did. Nurses generally rated female, African American, older patients’ pain higher and were more ready to prescribe opioids.

Johnson-Jennings et al, 2018 [65, 75]

To test whether patient-provider racial concordance and patient ethnic salience is associated with

1) provider pain assessment

2) attitudes toward referral for traditional healing practices for indigenous patients

USA

Primary care

Other clinical professional

1) Prescription 2) referral

Ethnicity (Indigenous American - high/low ethnic salience)

Racial concordance (patient & physician)

Chronic lower back pain

1) Indigenous providers rated patient with higher Indigenous ethnic salience more congruently with the self-reported pain ratings

2) Provider–patient racial concordance increased likelihood of consulting with and referring patients to traditional

healing practices.

Lutfey et al, 2009 & 2010 [66, 67]

1) Whether physician certainty is associated with decision making. Explore variations, by health care system, patient characteristics

2) whether observed disparities in CHD decision making are influenced by priming physicians to consider CHD.

USA, Germany and England

Primary care

Physician

Diagnosis, referral, prescription, lifestyle recommendations

Age, gender, ethnicity (black, white), SES

Diagnostic certainty, healthcare system, physician priming

CHD

1) Certainty was positively correlated with test ordering, prescriptions and specialist referrals. Physicians were least certain of CHD diagnoses when patients were younger and female.

2) Primed physicians were more likely to order CHD-related tests and prescriptions than unprimed but main effects for patient, gender and age remained.

Mckinlay et al, 2012 [68]

Whether physicians’ decisions to diagnose diabetes vary by race/ethnicity (after controlling for SES, age, and gender).

USA

Primary care

Physician

Diagnosis

Age, gender, ethnicity (black, Hispanic, white), SES

Effects of SES on ethnicity

Diabetes

Primary care physicians’ vignette diagnosis was patterned by race/ethnicity (rather than by SES). [Undiagnosed signs of T2DM in the community was patterned by SES rather than race/ethnicity.]

Papaleontiou, et al 2017 [69]

Understanding why older thyroid cancer patients are not being referred to high-volume surgeons.

USA

Primary care

Physician

Referral

Age

Physician training, patient volume, discipline & patient preferences

Cancer

Endocrinologists and physicians treating more than 10 thyroid cancer patients per year were more likely to refer older thyroid cancer patients than primary care physicians. Patient preference, transportation barriers and confidence in local surgeon were commonly reported reasons to decrease likelihood of referral.

Samuelsson et al, 2014 [70]

Disentangle a number of determinants on addiction care practitioners' perceptions of the severity of alcohol and drug consumption in clients.

Sweden

Addiction

Other

Referral (eligibility for services), perceptions of severity

Age, gender, ethnicity, SES, family circumstances

% variance due to vignette, professional and work unit

Substance use

Practitioners of different professional backgrounds and workplaces judge alcohol and drug consumption by different norms, and this was also influenced by characteristics of the users.

Shapiro, et al. 2018 [71]

Whether neonatologists show implicit racial and/or socioeconomic biases and whether these are predictive of recommendations at extreme periviability

USA

Acute

Physician

Care: comfort vs intensive (e.g. resuscitation)

Race, SES

Implicit bias

Periviability

Hypotheses were in part confirmed. Physicians with implicit socioeconomic bias were more likely to recommend comfort care to high than low SES vignettes but did not appear influenced by implicit racial bias.

Sheringham et al, 2017 [72]

How patients' clinical and sociodemographic characteristics influence GPs’ decisions to initiate lung cancer investigations

England

Primary care

Physician

Diagnosis

Age, gender, ethnicity (black, South Asian, white), SES

Information elicited, physician attributes

Respiratory symptoms

The information GPs elicited from patient vignettes influenced their decisions but did not explain observed ethnic inequalities in cancer investigations

Tinkler et al, 2018 [73]

Whether appointment offers to new US primary care patients who mention concerns about smoking or weight differ from offers to patients with no health concerns (healthy patients)

USA

Primary care

Other

Appointment offer

Insurance status, race/ethnicity, and gender

Health concerns (smoking/weight concerns vs healthy); state-level Medicaid expansion status

Disease prevention

Patients with smoking concerns were no more likely to be offered new patient appointments than healthy patients and less likely than those with weight concerns. Insurance status influenced access.

Wiltshire,et al. 2018 [74]

Whether concordance leads to higher ratings of trust in physicians amongst African American women race, gender and age

USA

Primary care

Public

Trust

Race - age, gender

Concordance

Breast exam

Older African-American women did not rate race, gender or age-concordant doctors higher on trust; instead they rated white, older male higher on competence than African-American older females.

  1. Key: SES socioeconomic status