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Pages 417-454

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From page 417...
... City University of New York Medical School INTRODUCTION At no time in the history of the United States has the health status of minority populations African Americans, Native Americans and, more recently, Hispanics, and several Asian subgroups equaled or even approximated that of white Americans. The health of all American racial and ethnic groups has improved dramatically, particularly over the last six decades, but the paired burdens of excess morbidity and decreased life expectancy for people of color have been noted over several centuries and have proved, even recently, to be stubbornly resistant to substantial change (Byrd and Clayton, 2000; National Center for Health Statistics, 1998~.
From page 418...
... The first of these is the contention that there are biologically and genetically distinct human races, and that "racial" biologic differences in susceptibility to, manifestations of, or therapeutic responses to specific diseases are significant pathophysiologic contributors to health disparities. Such beliefs appeared frequently in l9th-century America as elaborate, pseudoscientific arguments for the inherent biological inferiority of African Americans (Cartwright, 1851~.
From page 419...
... Studies of racial/ethnic disparities in diagnosis and treatment proliferated throughout the l990s and were characterized by increasingly sophisticated control or adjustment for such confounding variables as health insurance status, income and education, severity or stage of disease, comorbidity, and hospital type and resources. They drew upon a wide variety of datasources, regional and multi-center collaborations, quality assurance investigations, and disease-specific investigations such as the Coronary Artery Surgery Study (CASS)
From page 420...
... At the federal level, Congressional legislation has specifically addressed issues of discrimination in health care, and a new National Center on Minority Health and Health Disparities has been established at the National Institutes of Health. Clearly, the problem of racial/ ethnic disparities in diagnosis and treatment is increasingly being viewed as an important subset of the issue of achieving equity in health status (Department of Health and Human Services, 2000)
From page 421...
... In all, more than 600 bibliographic citations have been accumulated and organized primarily by disease category. Topics include general medical care, coronary artery and other cardiac disease, cancer, cerebrovascular disease, asthma, HIV/ AIDS, renal disease and renal transplantation, diabetes, mental health, maternal and child health, ophthalmic disease, prevention, and a small sampling of other disease categories.
From page 422...
... In subsequent sections, an attempt will be made to present representative studies in each of five disease categories. These examples from the literature review are intended to document the multiplicity of factors, including but by no means limited to individual and institutional bias, that contribute to racial and ethnic disparities in diagnosis and treatment.
From page 423...
... Despite the adequacy of health insurance coverage, black patients' utilization was substantially weighted toward lower-cost procedures. The authors concluded that "...providers appear to be giving less intensive care to otherwise similar black Medicare beneficiaries" (Lee et al., 1997~.
From page 424...
... The differences were particularly marked for vascular surgery and were attributed to lower rates of referral and access to specialty care (Gittelsohn, Halpern, and Sanchez, 1991~. A large retrospective cohort study of amputation rates and leg-sparing surgery for peripheral vascular disease among African-American and white Medicare beneficiaries found that among both diabetics and nondiabetics, African Americans were significantly more likely than whites to undergo amputations and significantly less likely to receive lower-extremity arterial revascularization (Guadagnoli et al., 1995~.
From page 425...
... After adjustment for age, coexisting disease, socioeconomic status, and potentially confounding clinical characteristics, African Americans were 32 percent less likely than whites to receive laparoscopic surgery (Arozullah et al., 1999~. In several other studies, African Americans were significantly less likely to receive total hip or total knee replacements, although racial variation in disease incidence may account for some of the differences (Harris and Sledge, 1990; Wilson, May, and Kelly, 1994; Baron et al., 1996~.
From page 426...
... , the pattern of results is clear: African Americans with CAD or AMI are significantly less likely to receive appropriate cardiac procedures or therapies (Maynard et al., 1986; Hannan et al., 1991; Udvarhelyi et al., 1992; Ayanian et al., 1993; Franks et al., 1993; Whittle et al., 1993; Peterson et al., 1994; Giles et al., 1995; Carlisle et al., 1995; Stone et al., 1996; Gornick et al., 1996; Sedlis et al., 1997; Weitzman et al., 1997; Peterson et al., 1997; Hannan et al., 1999; Canto et al., 2000~. They are less likely to be catheterized.
From page 427...
... The racial and ethnic disparities are not due to regional variations, since they have been found in all areas of the country. They are not due to patient choice or refusal of procedures by minority patients; although a few studies of heart disease have found such an effect, more recent prospective studies have indicated that it is far too small to account for the large differences in treatment rates.
From page 428...
... Since the authors found no significant interaction between the patient's race and the physician's race, they concluded that "racial discordance between the patient and the physician does not explain differences between black patients and white patients in the use of cardiac catheterization" (Chen et al., 2001~. The implication, fully articulated in an accompanying editorial, is that "overt racial prejudice did not account for racial differences in the rates of cardiac catheterization among black patients," presumably on the assumption that black physicians cannot be racially prejudiced (Epstein and Ayanian, 2001~.
From page 429...
... A large study at Duke Medical Center found the common pattern of significantly lower rates of CABG among African Americans. Those who did not receive such treatment included patients who were at highest risk, had two- or three-vessel disease, and would have been expected to gain the greatest benefit.
From page 430...
... A recent independent review of 61 studies published from 1966 to May 2000, examining racial variation in receipt of invasive cardiovascular procedures, reached conclusions strikingly similar to those in our own evaluations of the evidence. Among studies using administrative data, odds ratios extracted from the data by the authors for African-American patients compared with white patients ranged from 0.41 to 0.94 for cardiac catheterization, from 0.32 to 0.80 for angioplasty, and from 0.23 to 0.68 for CABG, and procedure rates were also found to be lower for Hispanic and Asian patients.
From page 431...
... After controlling for age, gender, clinical characteristics, and other variables, they found no racial differences in the rates of catheterization or revascularization (Taylor et al., 1997~. Cancer , A, ~ ~ , Studies of racial and ethnic disparities in cancer incidence and prevalence, screening, stage at diagnosis, treatment and survival uniquely illustrate the complex and multifactorial nature of the causes of such differences.
From page 432...
... Variation by race has also been found in patterns of treatment in some, but not all, studies. Black patients with breast cancer experienced "significantly different care" from whites on four of 10 treatment procedures, though they were not the most clinically important (Diehr et al., 1989~.
From page 433...
... Another study found that African-American women were less likely to receive breast conserving surgery, but the race effect disappeared after adjustment for stage at diagnosis, patients' educational level and rural or metropolitan residence. In a third such study, African Americans and whites received similar treatments (Velanovich et al., l999~.
From page 434...
... physicians present treatment options less fully to black patients, who may have less information about the disease and physicians make less enthusiastic recommendations to black patients for invasive procedures, among other differences in physician-patient communication; and (7) the differences are due to financial barriers and racial differences in ability to pay.
From page 435...
... " - r -- ) Renal Disease and Kidney Transplantation Among all minorities, African Americans and Native Americans suffer an excess risk of illness and death from end-stage renal disease (ESRD)
From page 436...
... Thus, the cumulative evidence for racial differences in access to and rate of transplantation is clear and powerful. As in other disease categories, however, the reasons for these disparities may involve many factors and are the subject of vigorous debate.
From page 437...
... When a large sample of ESRD patients in four regions of the United States were interviewed about their preferences, black patients were less likely than whites to want a transplant (Ayanian, Cleary, Weissman, and Epstein, 1999~. There were even larger racial differences, however, in the rates at which blacks and whites were fully informed of the options and referred for evaluation for a transplant, an essential step in offering a choice.
From page 438...
... A small study of physicians at one teaching hospital found that they felt more confident about giving an overview of clinical trials to white patients than to those of other races or ethnicities (Stone et al., 1998~. Patient
From page 439...
... The pattern of racial and ethnic disparities in diagnosis and treatment thus established is by no means limited to these diseases, but is similarly evident in all of the other major topics in our review. In psychiatric care, for example, African Americans are more likely than whites to be diagnosed as psychotic but are less likely to be given antipsychotic medications.
From page 440...
... There is no scientifically sound way of quantifying the role of individual or institutional bias, as compared with other causes, in creating racial and ethnic disparities in care. However, non-clinical influences on decision making by clinicians particularly the impact of race/ethnicity, social class, and culture have been identified and discussed for many years in the medical and social science literature (Geiger, 1957; Bloom, 1965; Freidson, 1973; Eisenberg, 1979; Henderson, 1985~.
From page 441...
... A littlenoticed finding in a British study of coronary revascularization procedures was that non-white patients are referred for revascularization less often than white patients with similar severity of disease (Hemingway et al., 2001~. A recent editorial in the British Medical Journal on racism in the National Health Service prompted a torrent of supportive letters and commentaries, though like the editorial itself they focused far more on perceived discrimination against Indian, Pakistani, Bangladeshi, African, and other minority physicians than on differential treatment of patients from these population groups (Bhopal, 2001~.
From page 442...
... Zuma, Minister of Health, July 15, 1996~. Implications for Change Earlier in this review it was noted that the major determinants of the deficits in health status of minority population groups in the United States were lack of access to care and differences in the social, physical and biological environments incomes, education, occupation, housing and nutrition which are themselves determined in part by persistent racism (Williams, 1998; Collins and Wiliams, l999~.
From page 443...
... Not all such bias is covert; openly pejorative racial comments on ward rounds have been described by many observers (Finucane and Carrese, 1990~. The first task, then, is to create increased recognition among providers of the existence and processes of stereotypical bias, and their role in the differential treatment of minority patients.
From page 444...
... Further research is essential, but implementation of corrective recommendations now should not be held in abeyance. The raw discrimination and blatant racism described by Myrdal nearly six decades ago of relegating African Americans and other minority patients to all-black hospitals, charity wards, or the basement wards of white hospitals have disappeared, but the scars of those past experiences remain, and subtler forms of differential treatment have emerged (Myrdal, 1944~.
From page 445...
... Relation of race and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction. New England Journal of Medicine.
From page 446...
... Krumholz HM. Racial differences in the use of cardiac catheterization after acute myocardial infarction.
From page 447...
... Racial differences in the use of invasive coronary procedures after acute myocardial infarction in Medicare beneficiaries. Ethnicity ~ Disease.
From page 448...
... Cerebrovascular disease in African Americans. Stroke.
From page 449...
... Theories explaining racial differences in the utilization of diagnostic and therapeutic procedures for cerebrovascular disease. Milbank Quarterly.
From page 450...
... Scientific silence: AIDS and African Americans in the medical literature. American Journal of Public Health.
From page 451...
... Racial differences in the identification of hypercholesteremia. Journal of Family Practice.
From page 452...
... Racial differences in performance of invasive cardiac procedures in a Department of Veterans Affairs Medical Center. Journal of Clinical Epidemiology.
From page 453...
... et al. Racial differences in the presentation and surgical management of breast cancer.
From page 454...
... Wood AJ. Racial differences in the response to drugs pointers to genetic differences.


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