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From page 125... ... 3 Assessing Potential Sources of Racial and Ethnic Disparities in Care: Patient- and System-Level Factors The literature reviewed earlier in this report demonstrates that evidence of racial and ethnic disparities in healthcare is persuasive and remarkably consistent across a range of health conditions and procedures, and cannot be fully explained by differences in access to care, such as insurance status. Moreover, the literature suggests several sources for these disparities. Read the entire page →
From page 126... ... 126 UNEQUAL TREATMENT healthcare. This literature is suggestive of a range of sources of disparities, some of which lie just beyond the conscious perception of individual actors (e.g., patients, providers, health systems administrators) Read the entire page →
From page 127... ... 127 PATIENT- AND SYSTEM-LEVEL FACTORS FIGURE 3-1 An integrated model of healthcare disparities. Central to this model is the role of personal discretion in determining the care that patients receive. Read the entire page →
From page 128... ... 128 UNEQUAL TREATMENT tervention are no less ambiguous. Significant variations in the incidence of many common medical and surgical procedures have been documented within small geographic areas and between individual practitioners (Wennberg, 1999) Read the entire page →
From page 129... ... 129 PATIENT- AND SYSTEM-LEVEL FACTORS throughs in treating and preventing disease. Despite these gains, however, many medical decisions must be made in the absence of solid evidence as to the efficacy of diagnostic and therapeutic measures or rigorous scientific understanding of the pathophysiology of disease (Mushlin, 1991) Read the entire page →
From page 130... ... 130 UNEQUAL TREATMENT standings of their patients' needs play a role; thus psychological sensitivity, cultural and language competency, and conscious and unconscious stereotypes and biases may also influence therapeutic decision-making. Further, uncertainty about treatment options in itself, even absent biases or stereotypes, can lead to disparate treatment of racial and ethnic minority groups, as will be discussed in Chapter 4. Read the entire page →
From page 131... ... 131 PATIENT- AND SYSTEM-LEVEL FACTORS PATIENT-LEVEL VARIABLES -- PREFERENCES, MISTRUST, TREATMENT REFUSAL, BIOLOGICAL DIFFERENCES, AND OVERUSE OF SERVICES Patients' Preferences To a great extent, patients' values, fears and hopes, and other psychological characteristics influence the level and type of care they receive. Patients' trust and doubts about medical advice, as well as their level of comfort with the effectiveness and potential unintended effects of interventions, directly influence their willingness to accept physicians' recommendations. Read the entire page →
From page 132... ... 132 UNEQUAL TREATMENT amples from focus group data presented in Chapter 2) or more subtle, subjective mistreatment (e.g., healthcare providers' low expectations for compliance or expressions of low empathy for minority patients) Read the entire page →
From page 133... ... 133 PATIENT- AND SYSTEM-LEVEL FACTORS relationship. Further, patients in race-concordant relationships rated their visits as significantly more participatory than patients in race-discordant relationships. Read the entire page →
From page 134... ... 134 UNEQUAL TREATMENT individuals from the dominant culture than white physicians have had to develop communication skills with individuals from minority cultures. This suggests that African-American physicians are likely to be bicultural (i.e., able to function effectively in the dominant culture as well as in minority cultures) Read the entire page →
From page 135... ... 135 PATIENT- AND SYSTEM-LEVEL FACTORS ceive catheterization within 60 days after MI. No significant differences were found, however, between African-American and white attending physicians in rates of catheterization among these patients. Read the entire page →
From page 136... ... 136 UNEQUAL TREATMENT American and 1,003 white cardiac patients, LaVeist, Nickerson, and Bowie (2000) found that while the majority of these patients did not tend to endorse the existence of widespread racism in medical settings, AfricanAmerican patients were four times more likely than whites to believe that racial discrimination is common in doctors' offices, and were significantly more likely to mistrust healthcare systems. Read the entire page →
From page 137... ... 137 PATIENT- AND SYSTEM-LEVEL FACTORS transluminal coronary angioplasty) when offered, compared with 8.3% among white patients, a difference that the authors conclude may help to explain observed differences in rates of receipt of procedures. Read the entire page →
From page 138... ... 138 UNEQUAL TREATMENT tive, perhaps in interaction with patients' attitudes and preferences. In addition, other studies find that minority patients are more likely than whites to perceive that discrimination is a problem in healthcare settings, and are more likely to believe that minority patients receive poorer care than non-minority patients. Read the entire page →
From page 139... ... 139 PATIENT- AND SYSTEM-LEVEL FACTORS ferences in the distribution of polymorphic traits -- including drug receptors or drug-metabolizing enzymes -- across all racial and ethnic groups, rather than traits unique to any one group (Wood, 2001) Read the entire page →
From page 140... ... 140 UNEQUAL TREATMENT among more than 26,000 patients meeting eligibility criteria as a result of acute MI. After controlling for clinical and demographic characteristics, the authors found that African Americans were slightly less likely than whites to undergo reperfusion therapy. Read the entire page →
From page 141... ... 141 PATIENT- AND SYSTEM-LEVEL FACTORS norities (Rice, this volume) Read the entire page →
From page 142... ... 142 UNEQUAL TREATMENT in a hospital emergency department to assess patients' reports of the use and need for interpretation. Interpretation, which is usually provided at the discretion of healthcare workers, was provided for only 26% of the Spanish-speaking patients. Read the entire page →
From page 143... ... 143 PATIENT- AND SYSTEM-LEVEL FACTORS from non-clinical employees (e.g., a clerk, aide, or custodian) or bilingual bystanders (e.g., other patients) Read the entire page →
From page 144... ... 144 UNEQUAL TREATMENT ences in the quality of care or mortality rates were found by race and poverty status. The authors note, however, that African-American patients and those who were from poor neighborhoods were 1.8 times as likely as whites and those not from poor neighborhoods to receive care in urban teaching hospitals, which generally provide better quality care. Read the entire page →
From page 145... ... 145 PATIENT- AND SYSTEM-LEVEL FACTORS in negotiating the medical bureaucracy. Thus, despite formal "equality" in access, minorities may experience differences in the rates with which they receive clinical services. Read the entire page →
From page 146... ... 146 UNEQUAL TREATMENT discussion of patient refusal) Read the entire page →
From page 147... ... 147 PATIENT- AND SYSTEM-LEVEL FACTORS Fragmentation of Healthcare Systems "Fragmentation" of healthcare can occur when patients, even those privately insured, encounter different levels of plan coverage that influence the kinds and quality of services they receive. Multiple coverage options offered by health plans are often characterized by different types of benefits packages and different degrees of provider choice. Read the entire page →
From page 148... ... 148 UNEQUAL TREATMENT restrict Medicaid beneficiaries' ability to access private physicians, and prevents many Medicaid patients from being admitted to hospitals in the absence of a private doctor with hospital admitting privileges (Rosenbaum, this volume) , unless admitted as "community service" inpatients. Read the entire page →
From page 149... ... 149 PATIENT- AND SYSTEM-LEVEL FACTORS factors were considered. In a study of prenatal birth outcomes among civilian and military women, Barfield et al. Read the entire page →
From page 150... ... 150 UNEQUAL TREATMENT system that provides patients' medical and social histories, discharge summaries and progress notes, allergies, prior laboratory results, and other information. Clinical reminder notifications provided through these computerized data systems are largely based on the VA's national clinical practice guidelines. Read the entire page →
From page 151... ... 151 PATIENT- AND SYSTEM-LEVEL FACTORS practice protocols and collect data on patient satisfaction and outcomes of care. As such, managed care offers the potential to help eliminate disparities in healthcare. Read the entire page →
From page 152... ... 152 UNEQUAL TREATMENT tion decisions, in that physicians' suspicions and fears about which patients will protest or sue if denied a test or treatment may influence (even at a subconscious level) the distribution of resources (Bloche, 2001) Read the entire page →
From page 153... ... 153 PATIENT- AND SYSTEM-LEVEL FACTORS were 10 times more likely than Asian Americans enrolled in other types of plans to express dissatisfaction with their usual source of care; Hispanics enrolled in managed care plans were 4 times more likely to express this belief; while whites enrolled in managed care plans were only 1.5 times more likely than whites enrolled in non-managed care plans to endorse this view. Research also suggests that managed care organizations' gatekeeper policies may pose greater barriers to care for minority patients. Read the entire page →
From page 154... ... 154 UNEQUAL TREATMENT eficiaries not subject to mandatory enrollment in managed care plans (TaiSeale et al., 2001) Read the entire page →
From page 155... ... 155 PATIENT- AND SYSTEM-LEVEL FACTORS larly treat, or because resource constraints such as capitation prevent physicians from meeting all patients' demands for services (Rice, this volume) Read the entire page →
From page 156... ... 156 UNEQUAL TREATMENT within the range of widely accepted clinical practice variations are thus not easily amenable to correction through the operation of medical malpractice law (Bloche, 2001) Read the entire page →
From page 157... ... 157 PATIENT- AND SYSTEM-LEVEL FACTORS emergency room screening have generally been construed and applied with similar permissiveness (Rosenblatt et al., 1997) Read the entire page →
From page 158... ... 158 UNEQUAL TREATMENT meant that private physicians were not subject to Title VI, despite the fact that virtually all other federal payments to private actors are treated by the regulations as "federal financial assistance," triggering Title VI protections (Rosenbaum, 2000) Read the entire page →
From page 159... ... 159 PATIENT- AND SYSTEM-LEVEL FACTORS held that Title VI did not create a private right of action concerning policies with disparate impact, absent discriminatory intent. This action therefore places the greatest burden of civil rights enforcement with U.S. Read the entire page →

From page 125...

... 3 Assessing Potential Sources of Racial and Ethnic Disparities in Care: Patient- and System-Level Factors The literature reviewed earlier in this report demonstrates that evidence of racial and ethnic disparities in healthcare is persuasive and remarkably consistent across a range of health conditions and procedures, and cannot be fully explained by differences in access to care, such as insurance status. Moreover, the literature suggests several sources for these disparities.