Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
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1. Introduction and Literature Review
1. Introduction and Literature Review
Pages 29-79
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From page 29... ...
In addition, some Asian-American subpopulations experience rates of stomach, liver, and cervical cancers that are well above national averages. The reasons for these health status disparities are complex and poorly understood, but may largely reflect socioeconomic differences, differences in health-related risk factors, environmental degradation, and direct and indirect consequences of discrimination (Williams, 1999~.
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From page 30... ...
Specifically, Congress requested that the IOM: · Assess the extent of racial and ethnic differences in healthcare that are not otherwise attributable to known factors such as access to care (e.g., ability to pay or insurance coverage) ; · Evaluate potential sources of racial and ethnic disparities in healthcare, including the role of bias, discrimination, and stereotyping at the individual (provider and patient)
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From page 31... ...
The term healthcare services refers to the provision of preventive, diagnostic, rehabilitative and/or therapeutic medical or health services to individuals or populations. Quality of care refers to the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
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From page 32... ...
Patient preferences that are not based on a full and accurate understanding of treatment options may therefore be a source of racial and ethnic disparities in care. The committee recognizes that patients' preferences and clinicians' presentation of clinical information and alternatives influence each other, but found separation of the two to be analytically useful.
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From page 33... ...
To summarize, racial and ethnic minorities are less likely than whites to posses health insurance (Collins, Hall, and Neuhaus, 1999) , are more likely to be beneficiaries of publicly funded health insurance (e.g., Medicaid [The Henry I
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From page 34... ...
To a great extent, attempts to separate the relative contribution of these factors risks presenting an incomplete picture of the complex interrelationship between racial and ethnic minority status, socioeconomic differences, and discrimination in the United States. For example, as will be discussed in Chapter 2, racial and ethnic housing segregation is a by-product of both historic and contemporary racism and discrimination, as well as socioeconomic differences (itself the legacy of poorer opportunities for many minority groups)
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From page 35... ...
These and other risk factors associated with health and poor health illustrate that racial and ethnic disparities in health status largely reflect differences in social, socioeconomic, and behavioral risk factors and environmental living conditions (House and Williams, 2000~. Healthcare is therefore necessary but insufficient in and of itself to redress racial and ethnic disparities in health status (Williams, 1999~.
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From page 36... ...
It is therefore important from an egalitarian perspective to expect equal performance in healthcare, especially for those disproportionately burdened with poor health. From a public health standpoint, racial and ethnic disparities in healthcare threaten to hamper efforts to improve the nation's health.
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From page 37... ...
Finally, for the population at large, racial and ethnic disparities in healthcare raise concerns about the overall quality of care in the United States. Given that racial and ethnic minority groups experience greater
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From page 38... ...
EVIDENCE OF RACIAL AND ETHNIC DISPARITIES IN HEALTHCARE The literature review that follows summarizes articles published in peer-reviewed journals within the last 10 years, with an emphasis on the most recent publications. In selecting literature to review, the committee identified studies that assess racial and ethnic variation in healthcare while controlling for differences in access to healthcare (e.g., by studying similarly insured patients or by statistically adjusting for differences in insurance status)
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From page 39... ...
In addition, as will be discussed below, no single study adequately controlled for all potential confounding factors (e.g., patient preferences, racial differences in disease severity or presentation, geographic availability of specific services or procedures) simultaneously.
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From page 42... ...
The preponderance of studies, however, find that even after adjustment for many potentially confounding factors including racial differences in access to care, disease severity, site of care (e.g., geographic variation or type of hospital or clinic) , disease prevalence, comorbidities or clinical characteristics, refusal rates, and overuse of services by whites racial and ethnic disparities in cardiovascular care remain.
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From page 43... ...
(1993) assessed racial differences in rates of revascularization following angiography and the relationship of these differences to hospital characteristics among more than 27,000 Medicare patients.
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From page 44... ...
non-teaching) , the authors found that white patients were 50% more likely to receive thrombolytics than black patients.
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From page 45... ...
The authors found no racial differences in rates of revascularization procedures among African-American patients (72%) , Hispanic patients (67%)
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From page 46... ...
(1999) studied the relationship between the availability of hospital-based invasive cardiac procedures and racial differences in the use of these services.
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From page 47... ...
to determine whether the acquisition of health insurance (ESRD patients are eligible for Medicare and generally enter a comprehensive system of care, if not already enrolled in one, upon diagnosis) could reduce racial and ethnic disparities in receipt of cardiovascular procedures (ESRD patients are at high risk for cardiovascular disease)
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From page 48... ...
These differences were not found among white patients similarly deemed appropriate for invasive treatment. Studies to Assess Appropriateness of Services Critics of many of the studies reviewed above charge that comparisons of minority patients' receipt of revascularization procedures with that of whites' may identify differences caused by overuse of procedures by whites, rather than clinical necessity.
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From page 49... ...
(1997) assessed racial differences in receipt of coronary angioplasty and CABG among patients with documented coronary disease, and assessed whether differences were associated with survival.
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From page 50... ...
Racial differences in clinical presentation or disease severity do not fully explain differences in receipt of services (Hannan et al., 1999; Lauori et al., 1997; Conigliaro et al., 2000; Canto et al., 2000) , although minority and non-minority patients may not respond equally well to some therapeutic interventions, as will be discussed in Chapter 3.
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From page 51... ...
These findings strongly suggest that access-related factors, such as insurance status, ability to pay, and characteristics of institutional and clinical settings are the largest contributors to observed racial and ethnic disparities in cardiovascular care. The vast majority of studies assessing disparities in cardiac care, however, find that racial and ethnic disparities persist even after variations in insurance status are controlled.
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From page 52... ...
found no evidence of racial and ethnic disparities in care after adjustment for racial and ethnic differences in insurance status, co-morbid factors, disease severity, and other potential confounders as noted above. The remaining studies found racial and ethnic disparities in one or more cardiac procedures, following multivariate analysis.
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From page 53... ...
. While African Americans were less likely than whites to have health insurance, were less likely to be treated by an experienced, board-certified physician, and were more likely to be treated in large, public hospitals, racial differences in care persisted when these and other clinical and demographic factors were controlled.
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From page 54... ...
assessed racial differences in of breast cancer survival among 246 black and white women who sought care for breast cancer in one of three health maintenance organizations (HMOs)
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From page 55... ...
Further, using survival analysis, the authors estimate that 308 African-American patients would have been alive at five years if black patients had undergone surgery at a rate similar to that of white patients. Racial and ethnic differences are also found in the use of analgesics to manage pain due to cancer.
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From page 56... ...
(1998) assessed racial differences in receipt of treatment and survival among 3,176 patients with colorectal cancer treated in the "equal access" Veterans Administration (VA)
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From page 57... ...
(1999) studied racial differences in rates of carotid artery imaging among patients diagnosed with transient ischemic attack, ischemic stroke, or amaurosis fugax seen at one of four VA Medical Centers.
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From page 58... ...
AfricanAmerican patients with ESRD, however, are less likely than similar white patients to receive a kidney transplant (Epstein et al., 2000~. AfricanAmerican patients are also less likely than white patients to be referred for transplantation and to appear on waiting lists within the first year of Medicare eligibility (Kasiske, London, and Ellison, 1998~.
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From page 59... ...
longitudinally followed adult ESRD patients to assess racial differences in rates of placement on transplantation waiting lists over time. The authors found that lower rates of placement on the waiting list for blacks than whites persisted after adjustment for differences in both sociodemographic characteristics and health status, and that the gap between blacks and whites did not narrow over time.
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From page 60... ...
found that African-American patients were less likely than white patients to be "definitely interested" in receiving a transplant, to complete pre-transplant workup, and finally, to progress on waiting lists to receive a transplant. These analyses controlled for patient age, gender, cause of renal failure, years receiving dialysis, and median income of patients' zip code area.
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From page 61... ...
(2000) , for example, in a study of relative risk of sixyear mortality for Hispanic, African-American, and white patients hospitalized as a result of HIV-related illness, found that Hispanics experience twice the risk of dying as whites, after controlling for sociodemographic characteristics, (e.g., access to care and insurance)
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From page 62... ...
Black and Hispanic patients at non-VA hospitals, however, were more likely to die during hospitalization, and were less likely to undergo bronchoscopy in the first two days of admission. No racial differences were found in use of bronchoscopy, receipt of anti-PCP medications within two days of admission, or mortality in VA hospitals.
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From page 63... ...
(2001) found that after controlling for patient age, education, employment, and symptom frequency, no significant differences existed between AfricanAmerican and white patients in use of medication regimens and asthma specialty care.
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From page 64... ...
found that even after controlling for patients' gender, education, and age, African-American patients were less likely to undergo a measurement of glycosylated hemoglobin, lipid testing, ophthalmologic visits, and influenza vaccinations than white patients. African-American patients with diabetes were also more likely to use hospital emergency departments and had fewer physician visits.
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From page 65... ...
A follow-up study (Todd, Lee, and Hoffman, 1994) revealed that physicians' assessments of pain severity did not differ among Hispanic and non-Hispanic white patients presenting to the emergency department with extremity trauma, ruling out physicians' ability to assess pain as a possible explanation for disparities in analgesic use.
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From page 66... ...
After adjusting for clinical and socioeconomic factors associated with the use of physical and occupational therapy, however, no racial differences were found in the likelihood of use of therapy or time to initiate therapy (African Americans = 6.6 days, whites = 7.4~. Similarly, no racial differences were found in length of physical or occupational therapy in days or as a proportion of hospital stay.
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From page 67... ...
among AfricanAmerican, Hispanic, and white women, and found inconsistent racial differences in these services, after controlling for maternal age, education, marital status, location of residence, birth order, timing of first prenatal care visit, and plural births. Amniocentesis was used substantially less frequently by black women, while black women underwent ultrasonography slightly less frequently than white women.
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From page 68... ...
Controlling for factors such as age, gender, cause of ESRD, family socioeconomic status (SES) , incident year of ESRD, ESRD network, and facility characteristics, the authors found that African-American youth were 12% less likely than white patients to be activated on the kidney transplant wait list.
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From page 69... ...
Surgeon General recently completed a major report assessing racial and ethnic disparities in mental health and mental healthcare that reviews much of the available literature. That report finds that more so than in other areas of health and medicine, mental health services are "plagued by disparities in the availability of and access to its services," and that "these disparities are viewed readily through the lenses of racial and cultural diversity, age, and gender" (U.S.
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From page 70... ...
An examination of privately insured federal employees, conducted by Padgett and colleagues (1994) , assessed racial and ethnic differences in use of inpatient psychiatric services.
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From page 71... ...
Racial and Ethnic Differences in Other Clinical and Hospital-Based Services Several studies document racial and ethnic disparities in other clinical and hospital-based services. Ebell et al.
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From page 72... ...
In another study of Medicare patients, Wilson, May, and Kelly (1994) assessed racial differences in receipt of total knee arthroplasty among older adults with osteoarthritis.
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From page 73... ...
assessed racial differences in use and level of use of prescription drugs among a sample of Medicaid patients, controlling for age, sex, and Medicaid eligibility characteristics. African-American children were found to use 2.7 fewer prescriptions compared with white children.
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From page 74... ...
(1995) assessed racial differences in the use of amputation and leg-sparing surgery among a random sample of Medicare patients.
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From page 75... ...
Most studies control for insurance status, but some combine data from patients insured via different types of health systems (e.g., HMO or fee-for-service) or different sources of insurance coverage (e.g., public vs.
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From page 76... ...
, and evaluated the magnitude of these differences above and beyond access-related factors such as insurance status, income, and other socioeconomic characteristics. The authors found that after adjusting for health insurance, income, age, sex, marital status, education, health status, region of the country, and residence in a metropolitan area, Hispanics and African Americans were significantly more likely to lack a usual source of care and were less likely to use any ambulatory care services than white Americans.
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From page 77... ...
The authors acknowledge, however, that these racial and ethnic disparities in the use of services could be related to unmeasured factors, such as job-related and non-financial barriers, poor cultural and linguistic access, an inadequate geographic distribution of healthcare providers in racial and ethnic minority communities, and other factors. More such studies are needed to assess the relative contribution of access-related factors (e.g., insurance status)
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From page 78... ...
Most studies have compared the quality of care received by minority patients relative to that of whites as the standard of comparison. This type of analysis, however, fails to provide a complete picture of the appropriateness of care, as whites may over-utilize some services, and racial differences in the severity of disease at presentation or treatment response may contraindicate the use of similar therapeutic interventions.
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From page 79... ...
Racial and ethnic disparities in healthcare exist. These disparities are consistent and extensive across a range of medical conditions and healthcare services, are associated with worse health outcomes, and occur independently of insurance status, income, and education, among other factors that influence access to healthcare.
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