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Pages 417-454

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From page 417...
... Racial and Ethnic Disparities in Diagnosis and Treatment: A Review of the Evidence and a Consideration of Causes H Jack Geiger, M.D.
From page 418...
... 418 UNEQUAL TREATMENT Classic public health doctrine holds that the major determinants of population health status and the primary explanations of disparities among population groups lie in the social, physical, and economic environments, which in turn are determined by the larger society's norms, values, social stratification systems and political economy (King, 1996; Menefee, 1996)
From page 419...
... 419 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT other sources initiated a growing stream of studies examining racial and ethnic disparities in diagnosis and treatment. These studies clearly established that whatever the causes, the experience of minorities within the health care system differed from that of comparable whites across a broad range of disease categories.
From page 420...
... 420 UNEQUAL TREATMENT ethnic physician-patient communication, in addition to the possibility of individual or institutional bias. In the late 1990s, concerns about racial/ ethnic bias and stereotyping appeared with increasing frequency in the medical literature (Geiger, 1996, 1997; King, 1996; Smith, 1998; Williams and Rucker, 2000)
From page 421...
... 421 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT reports from the Henry J Kaiser Family Foundation, the Commonwealth Fund, the Association of American Medical Colleges (AAMC)
From page 422...
... 422 UNEQUAL TREATMENT studies, selected as representative of the most important findings, will be described and discussed in the following section on general medical and surgical care. This will give some sense of the data sources, study designs and methods that are typical of the entire research effort.
From page 423...
... 423 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT of both basic and sophisticated diagnostic tests and minor and major surgical procedures, using claims data for Medicare beneficiaries in 10 states and the District of Columbia who had both Part A and Part B coverage. A subset of this sample was created by matching beneficiaries on the basis of zipcode of residence to neutralize the effects of black-white differences in provider access and regional practice patterns.
From page 424...
... 424 UNEQUAL TREATMENT ties may occur at every level of disease severity and at every stage of the diagnostic and therapeutic process, they have the limitations described previously. Most are retrospective, and cannot report information gleaned directly from providers or patients.
From page 425...
... 425 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT Researchers examining a prospective clinical records file covering all VA hospitals with operating rooms studied the use of laparoscopic versus conventional open cholecystectomy (which has a much higher in-hospital death rate) in the first four years after the introduction of the newer method.
From page 426...
... 426 UNEQUAL TREATMENT beta-blockers, thrombolytic drugs, and aspirin. The reasons for the abundance of CAD-related studies are apparent.
From page 427...
... 427 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT the causes of these inequalities in care remain to be fully elucidated, the studies have clarified what does not explain them (East and Peterson, 2000)
From page 428...
... 428 UNEQUAL TREATMENT counting for the strong association between race and payor status, as well as gender, disease severity and age, the baseline racial differences were not diminished in any phase (Blustein et al., 1995)
From page 429...
... 429 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT black and white cardiologists made for patients of either race. In a comment on Chen et al., Barr pointed out that as many as 70 percent of all the patients were likely to have had a cardiac consultation, and given that there are only a few hundred black cardiologists and more than 18,000 white cardiologists, it is likely that most black patients were seen by white cardiologists (Barr, 2001)
From page 430...
... 430 UNEQUAL TREATMENT physician who made the decision not to recommend the procedure (Hannan et al., 1999)
From page 431...
... 431 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT that affect their clinical decisions. This effect may be a direct consequence of conscious bias (Finucane and Carese, 1990)
From page 432...
... 432 UNEQUAL TREATMENT were found to account for findings that elderly blacks had significantly lower experience of regular cancer preventive services such as mammograms, Pap tests, clinical breast examinations, rectal examination and fecal occult blood testing (Hegarty et al., 2000)
From page 433...
... 433 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT American, Hispanic, and white women (Farrow, Hunt and Samet, 1992; Satariano, Swanson, and Moll, 1992)
From page 434...
... 434 UNEQUAL TREATMENT Stroke African Americans suffer strokes at a rate as much as 35 percent higher than whites, and the death rate among those suffering strokes is twice as high among blacks as whites (Gillum, 1986; Gorelick, 1998; Ness and Aranow, 1999)
From page 435...
... 435 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT ferent from that of a patient facing a real-world choice, and the sample size was small. In a 1993 VA study, black patients were found to be only one-third as likely as whites to receive carotid angiography, the essential diagnostic precursor to a decision regarding endarterectomy, and Hispanics were less than half as likely as whites to do so (Oddone et al., 1993)
From page 436...
... 436 UNEQUAL TREATMENT transplant. If they do receive a cadaveric or donor kidney, they are more likely to suffer transplant failure.
From page 437...
... 437 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT Many studies have provided evidence that African-American patient preferences, including refusal of or disinterest in the possibility of transplantation, is an important contributor. A number of recent investigations have cast light on the nuances and complexities of both patient and provider behavior.
From page 438...
... 438 UNEQUAL TREATMENT Studies that have addressed such disparities have focused far more on patient behaviors than on possible provider contributions to such differences. Considerable attention has been paid to potential explanatory variables such as patient preferences and attitudes, lack of knowledge or understanding, and mistrust of the health care system, in addition to such familiar issues as differences in socioeconomic status, lack of health insurance, problems of access to care, and apparent biologic differences in response to medication.
From page 439...
... 439 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT mistrust is also described as a factor. Among 520 black adults in 10 randomly selected census tracts, 27 percent agreed with the statement that "HIV/AIDS is a man-made virus that the federal government made to kill and wipe out black people," and an additional 23 per cent were undecided (Klonoff and Landrine, 1999)
From page 440...
... 440 UNEQUAL TREATMENT health care, provider and institutional bias are significant contributors -- a possibility raised repeatedly, if reluctantly, by many researchers. This conclusion is explicitly supported by a number of studies in which providers' views have been assessed or in which decision-making physicians have been blinded to patient race or ethnicity.
From page 441...
... 441 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT Racial and Ethnic Disparities in Care: A Global Problem? It is useful to note that differential treatment of minorities, particularly people of color, is not a uniquely American phenomenon.
From page 442...
... 442 UNEQUAL TREATMENT problems of differential treatment of the Inuit people in Canada and emphasized the need for greater cultural competence on the part of physicians (Masi, 1989; Hamilton, 1996; Young et al., 2000)
From page 443...
... 443 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT sional African-American woman who is assumed by an emergency room clinician to be an unemployed welfare recipient (Gamble, 1997)
From page 444...
... 444 UNEQUAL TREATMENT Finally, the limitations of much of the research on disparities in race and ethnicity underscore the need for prospective studies, with access to detailed clinical records. This may be particularly important in understanding the variations in verbal and nonverbal physician-patient communication in both race-concordant and race-discordant physician-patient dyads.
From page 445...
... 445 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT Baron JA, Barrett J, Katz JN, Liang MH. Total hip arthroplasty: Use and select complications in the U.S.
From page 446...
... 446 UNEQUAL TREATMENT Carlisle DM, Leake BD, Shapiro MF. Racial and ethnic differences in the use of invasive cardiac procedures among cardiac patients in Los Angeles County, 1986 through 1988.
From page 447...
... 447 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT Easterbrook P, Keruly JC, Creagh-Kirk T, Richman D, Chaisson RE, Moore RD. Racial and ethnic differences in outcome in Zivoduvine-treated patients with advanced HIV dis ease.
From page 448...
... 448 UNEQUAL TREATMENT Gittelsohn AM, Halpern J, Sanchez RL. Income, race, and surgery in Maryland.
From page 449...
... 449 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT Hemingway H, Crook AM, Feder G, et al. Underuse of coronary revascularization proce dures in patients considered appropriate candidates for revascularization.
From page 450...
... 450 UNEQUAL TREATMENT Leape LL, Hilborne LH, Bell R, Kanberg C, Brook RH. Underuse of cardiac procedures: Do women, ethnic minorities, and the uninsured fail to receive needed revascularization?
From page 451...
... 451 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT National Center for Health Statistics. Health, United States, and Socioeconomic Status and Health Chartbook.
From page 452...
... 452 UNEQUAL TREATMENT Rathore S, Berger AK, Weinfurt KP, et al. Race, sex, poverty and the medical treatment of acute myocardial infarction in the elderly.
From page 453...
... 453 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT Trock B, Rimer BK, King E, Balshem A, Christinzio CS, Engstrom PF. Impact of an HMO based intervention to increase mammography utilization.
From page 454...
... 454 UNEQUAL TREATMENT Wilson MG, May DS, Kelly JJ. Racial differences in the use of total knee arthroplasty for osteoarthritis among older Americans.

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