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B Literature Review The study committee conducted an extensive review of literature on racial and ethnic disparities in healthcare (discussed in Chapter 1). In this appendix, summary tables of this literature are presented, along with cri- teria used in the conduct of this review. To assess the evidence regarding racial and ethnic differences in health care, the committee conducted literature searches via PUBMED and MEDLINE databases to identify studies examining racial and ethnic differences in medical care for a variety of disease categories and clini- cal services. Searches were performed using combinations of following keywords: • Race, racial, ethnicity, ethnic, minority/ies, groups, African Ameri- can, Black, American Indian, Alaska Native, Native American, Asian, Pa- cific Islander, Hispanic, Latino. • Differences, disparities, care. • Cardiac, coronary, cancer, asthma, HIV, AIDS, pediatric, children, mental health, psychiatric, eye, ophthalmic, glaucoma, emergency, diabe- tes, renal, gall bladder, ICU, peripheral vascular, transplant, organ, cesar- ean, prenatal, hip, hypertension, injury, surgery/surgical, knee, pain, pro- cedure, treatment, diagnostic. This search yielded over 600 citations. To further examine this evi- dence base and address the study charge that called for an analysis of “the 285

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286 UNEQUAL TREATMENT extent of racial and ethnic differences in health care that are not otherwise attributable to known factors such as access to care,” only studies that provided some measure of control or adjustment for racial and ethnic dif- ferences in insurance status (e.g., ability to pay/insurance coverage or co- morbidities) were included in the literature review. Other “threshold” cri- teria included: • Publication in past 10 years (1992-2002; this criterion was estab- lished because more recent studies tend to employ more rigorous research methods and present a more accurate assessment of contemporary pat- terns of variation in care); • Publication in peer-reviewed journals; • Elimination of studies focused on racial and ethnic differences in health status (except as it is affected by the quality of health care) and health care access, as well as publications that were editorials, letters, pub- lished in a foreign language, were non-empirical, or studies that controlled for race or ethnicity; and • Inclusion only of studies whose primary purpose was to examine variation in medical care by race and ethnicity, contained original find- ings, and met generally established principles of scientific research (e.g., studies that stated a clear research question, provided a detailed descrip- tion of data sources, collection, and analysis methods, included samples large enough to permit statistical analysis, and employed appropriate sta- tistical measures). In addition, to ensure the comprehensiveness of the review, the com- mittee examined the reference lists of major review papers that summa- rize this literature (e.g., van Ryn, 2002; Geiger, this volume; Kressin and Petersen, 2001; Bonham, 2001; Sheifer, Escarce, and Schulman, 2000; Mayberry, Mili, and Ofili, 2000; Ford and Cooper, 1995). Articles not originally identified in the initial search were retrieved and analyzed for appropriateness of inclusion in the committee ’ s review. Finally, to ensure that the committee’s search was not limited to studies with “positive” findings of racial and ethnic differences in care, searches were conducted for studies that attempted to assess variations in care by patient socioeconomic status and geographic region. These studies were included if the researchers assessed racial or ethnic differences in care while controlling, as noted above, for patient access-related factors.

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287 B: LITERATURE REVIEW To assess the quality of this evidence base, the committee ranked stud- ies on several criteria: • Adequacy of control for insurance status (studies of patients cov- ered under the same health system or insurance plan were considered to be more rigorous than studies that merely assessed the availability of health insurance among the study population); • Use of appropriate indicators for patient socioeconomic status (e.g., studies that measured patients’ level of income, education, or other indi- cators of socioeconomic status); • Analysis of clinical data, as opposed to administrative claims data (see limitations of administrative claims data noted below); • Prospective or retrospective data collection (prospective studies were considered to be more rigorous than retrospective analyses); • Appropriate control for patient co-morbid conditions; • Appropriate control for racial differences in disease severity or stage of illness at presentation; • Assessment of patients’ appropriateness for procedures (e.g., stud- ies that provide primary diagnosis and include well-defined measures of disease status, as in studies of cardiovascular care that assess racial differ- ences in care following angiography) or that compare rates of service use relative to standardized, widely-accepted clinical guidelines; and • Assessment of racial differences in rates of refusal or patient pref- erences for non-invasive treatment. Studies that met the committee’s “threshold” criteria are summarized in Table B-1. As a “second level” analysis of the quality of evidence regarding ra- cial and ethnic disparities in cardiovascular care, the committee identified a subset of studies that permit a more detailed analysis of the relationship between patient race or ethnicity and quality of care, while considering potential confounding variables such as clinical differences in presenta- tion and disease severity. Several criteria were established to identify these studies, using generally accepted criteria of research rigor and quality. To begin, the committee identified only studies using clinical, as opposed to administrative data, for the reasons cited above. Secondly, the committee identified studies that provided appropriate controls for likely confound- ing variables, and/or employed other rigorous research methods. These

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288 UNEQUAL TREATMENT criteria included the use of adequate control or adjustment for racial and ethnic differences in insurance status; prospective, rather than retrospec- tive data collection; adjustment for racial and ethnic differences in co- morbid conditions; adjustment for racial and ethnic differences in disease severity; comparison of rates of cardiovascular services relative to mea- sures of appropriateness; and assessment of patient outcomes. Several caveats should be noted in undertaking this approach. One, studies using clinical data allow researchers to better assess whether dis- parities in care exist and are significant after potential confounding fac- tors such as clinical variation and the appropriateness of intervention are taken into account, but these studies often are limited to small patient samples in one or only a few clinical settings, therefore sacrificing statisti- cal power and potentially underestimating the role of institutional vari- ables as contributing to healthcare disparities. Second, assessments of ra- cial and ethnic differences in patients’ clinical outcomes following intervention must be made with caution. Patients’ outcomes following medical intervention reflect a wide range of factors, some of which are unrelated to the intervention itself (e.g., the degree of social support avail- able to patients following treatment) and may vary systematically by race or ethnicity. In addition, a finding of no racial or ethnic differences in patient outcomes (e.g., survival) despite disparate rates of treatment should not be interpreted as demonstrating that disparities in the use of medical intervention are inconsequential. In such instances, researchers should ask whether equivalent rates of intervention might be associated with better patient outcomes among minorities. Finally, this second level of analysis should not be interpreted as suggesting that the larger litera- ture presented above is insufficient to draw conclusions regarding dis- parities in healthcare. Almost all of the individual studies reviewed ear- lier possess limitations, but the collective body of this evidence is robust. Despite these caveats, this second review afforded an opportunity to assess whether racial and ethnic disparities in care remain when racial differences in clinical presentation and other potentially confounding vari- ables are controlled. Studies were considered in this second review only if they met four of six criteria noted above, in addition to the “threshold” criteria that studies employ clinical databases. Thirteen studies were iden- tified through this process (see Table B-2). Of these, only two (Leape et al., 1999; Carlisle et al., 1999) found no evidence of racial and ethnic dispari- ties in care after adjustment for racial and ethnic differences in insurance status, co-morbid factors, disease severity, and other potential confounder

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289 B: LITERATURE REVIEW as noted above. The remaining studies found racial and ethnic disparities in one or more cardiac procedures, following multivariate analysis. Al- most all studies found that adjustment for one or more confounding fac- tors reduced the magnitude of unadjusted racial and ethnic differences in care. Among the five studies that collected data prospectively, however, all found racial and ethnic disparities remained after adjustment for con- founding factors.

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290 UNEQUAL TREATMENT TABLE B-1 Summary of Selected Literature—Racial and Ethnic Disparities in Health Care Analgesia Source Procedure/Illness Sample Analyses Todd, Deaton, Assessed racial differences in Retrospective cohort study of D’Adamo, and Goe, receipt of analgesia among 217 patients (127 African 2000 patients seen for extremity American, 90 white) seen in fractures in emergency an emergency department in departments. an urban hospital. Bernabei, Gambassi, Assessed adequacy of pain 13,625 cancer patients (12,038 Lapane et al., 1998 management among elderly white, 1,041 African Ameri- and minority cancer patients can, 163 Hispanic, 107 Asian, admitted to nursing homes. 276 American Indian) dis- charged from hospitals to any of 1,492 Medicare-certi- fied/Medicaid-certified nursing homes in five states.

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291 B: LITERATURE REVIEW Analyses Findings Limitations Multiple logistic regressions Nearly three-fourths of white pa- -Moderate sample size. to predict use of analgesia tients (74%) received analgesia, -Racial/ethnic groups by race, controlling for time compared to 57% of African Ameri- other than white and since injury, total time in can patients. The crude risk of African American not the emergency department, receiving no analgesia was 66% sampled. payer status, and need for higher for black patients than white. -One site sampled. fracture reduction. After controlling for covariates, -Retrospective study. whites remained significantly more -Other relevant con- likely to receive analgesia (risk founds such as alco- ratio = 1.7, 95% CI 1.1 to 2.3). hol and drug use not considered. -Few racial/ethnic minority physicians in sample. Logistic regression to pre- More than a quarter of patients in -Small numbers in dict unresolved daily pain, daily pain (26%), as assessed by self- racial/ethnic groups. adjusting for gender, cogni- report and independent raters, -Retrospective, cross- tive status, communication received no pain medication. After sectional study. skills, and indicators of adjustment, African Americans had -Data set not specifi- disease severity (e.g., ex- 63% greater probability of being cally focused on pain. plicit terminal prognosis), untreated for pain relative to whites -Pain assessed by ob- being bedridden, number of (odds ratio = 1.63, 95% CI 1.18 to servational evaluation. diagnoses, and use of other 2.26). Older age, low cognitive -Family members medications. performance, and increased number involved in collection of other medications were also of information to associated with failure to receive varying degrees. any analgesic agent. -No data regarding analgesic dose or frequency of administration.

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292 UNEQUAL TREATMENT TABLE B-1 Continued Analgesia Source Procedure/Illness Sample Analyses Cleeland, Gronin, Baez Assessed adequacy of pain 281 minority outpatients (106 et al., 1997 management among minority African American, 94 His- patients receiving care in panic, 16 other minority) with settings that primarily serve recurrent or metastatic cancer minorities vs. patients who at 9 university cancer centers, receive care in settings where 17 community hospitals and few minority patients are practices, and 4 centers that treated. primarily treat minority patients. Ng, Dimsdale, Rollnik, Assessed racial/ethnic differ- 454 (314 white, 37 Asian, 73 and Shapiro, 1996 ences in physicians prescrip- Hispanic, 30 African Ameri- tion of patient-controlled can) consecutive patients analgesia for post-operative receiving patient-controlled pain. analgesia in post-operative period.

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293 B: LITERATURE REVIEW Analyses Findings Limitations Compared treatment of Sixty-five percent of patients who -Data regarding pain among this sample reported pain received inadequate race/ethnicity not with a larger, primarily pain medication. Patients treated in available for com- white sample from a previ- settings where the patient population parison group. ous study where partici- was primarily black or Hispanic and -Data collected pants were treated in set- those who were treated at university immediately after tings where fewer than 10% centers were more likely to receive data on the non- of patients were ethnic inadequate analgesia (77%) than those minority compari- minorities. Pain assessed by who received treatment in settings son group col- independent ratings of where patient population was prima- lected. patients and physicians. rily white (52%; p < 0.003). In addi- -No data collected Adequacy of analgesia tion, minority patients were more on ability to pay. estimated by widely ac- likely to be undermedicated for pain cepted measure of treat- than white patients (65% vs. 50%; p < ment of pain. 0.001), and were more likely to have the severity of their pain underesti- mated by physicians. Analysis of variance and No significant differences found in -Relatively small post-hoc LSD-tests using patient rating of pain or amount of numbers of African ethnicity as independent analgesia self-administered. Americans and Asians. variable. Dependent vari- -Sample located at ables include amount of Significant differences in the amount of one site. narcotic prescribed and narcotic prescribed among Asians, -Retrospective study. amount of narcotic self- blacks, Hispanics, and whites (F = -Analyses did not administered. 7.352; p < 0.01). Whites and African control for patient Americans were prescribed more size or primary narcotic than Hispanics and Asians. language. After adjustment for age, gender, pre- operative use of narcotics, health insurance, and pain site, ethnicity persisted as independent predictor of amount of narcotic prescribed.

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294 UNEQUAL TREATMENT TABLE B-1 Continued Analgesia Source Procedure/Illness Sample Analyses Todd, Lee, and Assessed racial/ethnic differ- Prospective study of 207 pa- Hoffman, 1994 ences in physician’s percep- tients (138 white, 69 Hispanic) tions of pain in patients with admitted to ED at UCLA Medi- isolated extremity trauma. cal Center between 1992-1993. Todd, Samaroo, and Assessed ethnic differences in 139 patients (108 white, 31 Hoffman, 1993 receipt of emergency depart- Hispanic) admitted to emer- ment analgesia for isolated gency department at UCLA. long-bone fractures. Patients with recorded alcohol or drug use excluded.

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295 B: LITERATURE REVIEW Analyses Findings Limitations Analysis of Covariance to No differences found between non- -Patients enrolled evaluate influence of con- Hispanic and Hispanic patients in study primarily in founding variables on the patient pain assessment, physician early evening and relationship between ethnic- pain assessment, or disparity between weekends. ity and differences in pa- patient and physician pain assess- -Moderate samples tient and physician pain ment. Differences remained non- size. assessment. Independent significant after controlling for -Racial groups variables included occupa- confounds. other than Hispanic tional injury, injury loca- and white not tion, patient pain assess- sampled. ment, physician sex, injury -Single site sampled. type, insurance status, and patient ethnicity. Logistic regression to evalu- 55% of Hispanic patients and 26% of -Retrospective study. ate independent influence of white patients received no analgesic -No control for race/ethnicity on probability (crude relative risk = 2.12, 95% CI covariates such as of analgesic administration. 1.35 to 3.32, p = 0.003). After simulta- precise injury, pres- Independent variables neously controlling for covariates ence of translators. included race/ethnicity, Hispanic ethnicity was strongest -Single site. gender, language, insurance predictor of no analgesia (odds ratio = -Small sample size. status, occupational injury, 7.46, 95% CI 2.22 to 25.04, p < 0.01). -Small number of fracture reduction, time of Hispanics in sample. presentation, total time in -Racial/ethnic ED, hospital admission. groups other than white and Hispanic not sampled.

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373 B: LITERATURE REVIEW Analyses Findings Limitations maker implant, and auto- (odds ratio = 1.49, 95% CI 1.35 to matic cardioverter-defibril- 1.67). lator implant. Whites were more likely than Asian patients to receive endarterectomy (odds ratio = 2.08, 95% CI 1.18 to 3.85) and angioplasty (odds ratio = 1.30, 95% CI 1.15 to 1.47). Asians were more likely than whites to receive hip replacement (odds ratio = 0.47, 95% CI 0.29 to 0.77). Males’ odds of receiving most proce- dures exceeded those of females. Multiple regression to B/w differences found in: -Racial/ethnic predict utilization rates by mortality: 1.19 men (p < 0.001), 1.16 groups other than race-specific median in- women (p < 0.001) African American come, age, gender, and hospital discharges: 1.14, p < 0.001 and white not interaction of race and ambulatory care visits: 0.89, p < 0.001 examined. income. bilateral orchiectomy: 2.45, p < 0.001 -Administrative data. amputations of lower limbs: 3.64, p < -Retrospective study. 0.001 -Factors such as Adjusting for differences in income clinical, hospital reduced differences, but not characteristics not significantly. assessed as poten- tial confounds. Logistic regression to assess Black patients utilized significantly -Highly selective independent effect of race fewer resources than patients of other sample. on procedure use, control- races (odds ratio = 0.70, 95% CI 0.6 to -Data on SES vari- ling for age, gender, educa- 0.81). The median adjusted difference ables not available tion, income, type insur- in hospital cost was $2,805 lower for for all subjects. ance, severity of illness, black patients (95% CI $1,672 to $3,883 functional status, study site, less). Results remained significant and other confounding after adjusting for physician’s percep- variables tions of patients’ prognosis.

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374 UNEQUAL TREATMENT TABLE B-1 Continued Use of services and procedures—General Analgesia Source Procedure/Illness Sample Analyses Wilson, May, and Assessed racial differences in Records of nearly 300,000 Kelly, 1994 receipt of total knee arthro- Medicare recipients who plasty among older adults underwent total knee arthro- with osteoarthritis. plasty between 1980 and 1988. Escarce, Epstein, Racial differences in use of 1986 physician claims data for Colby, and Schwartz et medical procedures among 1,204,022 Medicare enrollees al., 1993 Medicare enrollees. (1,109,954 whites and 94,068 African Americans). Indi- viduals enrolled in HMOs excluded. Vaccination Schneider et al., 2001 Magnitude of racial differ- Data from 1996 Medicare ences in influenza vaccination Current Beneficiary Survey. in managed care vs. fee-for- 13,674 Medicare beneficiaries service insurance. (12,414 white, 1,260 African American).

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375 B: LITERATURE REVIEW Analyses Findings Limitations Natural logarithm transfor- The prevalence of symptomatic os- -Racial/ethnic groups mation method to estimate teoarthritis of the knee was lower other than African confidence intervals for among whites than blacks, although American and white white-to-black ratios of this difference was non-significant. not examined. rates of total knee replace- African Americans, however, were -Administrative data. ment. less likely than whites to receive total -Retrospective study. knee arthroplasty (odds ratios ranged -Clinical, SES, from 1.5 to 2.0 for women, 3.0 to 5.1 hospital factors, for men). This disparity persisted at appropriateness not each of five levels of income strata. explored as con- founds. Mantel-Haenszel method to Whites more likely than African -Racial/ethnic calculate white-black rela- Americans to receive 23 of 32 services groups other than tive risks, adjusting for age (white-black RR > 1.0, p < 0.05). For African American and sex. example, whites were 1.5 to 2.0 times and white not as likely to receive eight of the study assessed. services, 2.0 to 3.0 times as likely to -Administrative receive three of the services, and more data. than 3.0 times as likely to receive -Retrospective coronary bypass, coronary angio- study. plasty, and carotid endarterectomy. -Potential con- founds such as SES African Americans were more likely and clinical and than whites to receive seven services hospital characteris- (white-black RR < 1.0, p < 0.05). For tics not assessed. example, African Americans more than 1.5 times as likely to receive laser trabeculoplasty, glaucoma surgery, and retinal photocoagulation. Percentage of respondents Both whites and African Americans -Racial/ethnic (adjusting for SES, clinical had higher rates of vaccination under groups other than comorbidities, and care- managed care, however racial dispar- African American seeking attitudes) who ity was not reduced under managed and white not received vaccination and care. examined. magnitude of racial dispar- -Potential bias in ity in vaccination was After adjustment, the racial disparity self-report data. calculated, comparing in fee for service was 24.9% (95% CI patients with managed care. 19.6% to 30.1%). The disparity in managed care was 18.6% (95% CI 9.8% to 27.4%). Both disparities were statistically significant, however the

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376 UNEQUAL TREATMENT TABLE B-1 Continued Analgesia Use of services and procedures—General Source Procedure/Illness Sample Analyses Women’s Health Brown, Perez-Stable, Hormone Replacement 8,986 women (50% white, Whitaker, Posner et al., Therapy (HRT). 20.2% Asian, 14.7% African 1999 American, 8.6% Latina, 6.3% Soviet immigrant) seen in the general internal medicine, family medicine, and gynecol- ogy practices at UCSF between January 1, 1992, and November 30, 1995. Marsh, Brett, and Hormone replacement 25,203 sampled visits made by Miller, 1999 therapy (HRT). women (age 45-64, 16.4% by black and 83.6% by white women). Data were obtained from the National Health Care survey.

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377 B: LITERATURE REVIEW Analyses Findings Limitations and those with fee-for- absolute percentage point difference service insurance. in racial disparity between the man- aged care and fee-for-service groups (6.3%, 95% CI -4.6% to 17.2%) was not. Logistic regression was Compared to white women, all other -Single site. used to calculate odds of groups were less likely to be pre- -Retrospective prescribing HRT for each scribed HRT after adjusting for age, review. ethnic group using whites income, diabetes, hypertension, CHD, -Data not available as the reference group. and osteoporosis. Asians (odds ratio = on variables such Predictor variables were 0.56, 95% CI 0.49 to 0.64), African as education, age, income, and clinical Americans (odds ratio = 0.70, 95% CI menopausal symp- diagnosis. 0.60 to 0.81)), Latinas (odds ratio = toms, hysterectomy 0.70, 95% CI 0.58 to 0.84), and Soviet status, etc. immigrants (odds ratio = 0.14, 95% CI -Physician recom- 0.10 to 0.20) were each less likely to mendations or receive a prescription for HRT than patient characteris- were white women. Women with tics not assessed. osteoporosis were also more likely to receive HRT. Logistic regression used to While physician visit rates were equal -Racial/ethnic examine whether any previ- for black and white women, the rate groups other than ously identified racial dif- of visits per year in which HRT was African American ferences in HRT could be prescribed to white women (odds and white not attributed to known con- ratio = 0.38, 95% CI 0.32 to 0.45) was examined. founders (age, source of more than twice the rate for black -Retrospective payment for visit, drugs women (odds ratio = 0.17, 95% CI 0.12 study. other than HRT, whether to 0.23) in this age group. -Limited informa- physician had previously tion on patient seen patient, physician or characteristics. clinic specialty type, site of care, region of practice, obesity, duration of visit, physician sex).

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378 UNEQUAL TREATMENT TABLE B-1 Continued Analgesia Health Women’s Source Procedure/Illness Sample Analyses Burns, McCarthy, Mammography. 3,187,116 women (7% black, Freund, Marwill et al., 93% white) ages 65 and older 1996 receiving Medicare who re- sided in one of the following states, Alabama, Arizona, Connecticut, Georgia, Kansas, New Jersey, Oklahoma, Penn- sylvania, Oregon, or Washing- ton. Women had received bilateral mammography. Data were obtained from HCFA database for 1990.

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379 B: LITERATURE REVIEW Analyses Findings Limitations Logistic regression to pre- In every state, at each primary care -Racial/ethnic dict mammography use visit level (one, two, or three or more groups other than according to age, number of visits) black women had mammogra- African American primary care visits, income, phy less often than white women and white not state of residence for black (even across income levels). Age, examined. and white women in each income, and state adjusted logistic -Administrative state. models reveal that among white data. women, primary care use has a sig- -Retrospective nificant effect on use of mammogra- study. phy: for one visit odds ratio = 2.73, 95% CI 2.70 to 2.77, for two visits odds ratio = 3.98, 95% CI 3.93 to 4.03, for three or more visits odds ratio = 4.62, CI 4.58 to 4.67. Results for black women reveal an analogous, but weaker effect: for one visit odds ratio = 1.77, CI 1.67 to 1.87, for two visits odds ratio = 2.49, CI 2.36 to 2.63, for three or more visits odds ratio = 3.15, CI 3.04 to 3.25.

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380 UNEQUAL TREATMENT TABLE B-2 Selected Studies Exerting Control Over Key Clinical Characteristics Type Prospective/ Adjust for: Disease Author Year of Data Insurance Retrospective Comorbidities? Severity Petersen 2002 Clinical VA healthcare Retrospective Yes et al. system Conigliaro 2000 Clinical VA healthcare Retrospective Yes et al. system Carlisle et al. 1999 Clinical Statistical adjust- Retrospective No records ment for type of and ED insurance logs Daumit et al. 1999 Clinical ESRD Medicare Prospective Yes Hannan et al. 1999 Clinical Statistical adjust- Prospective Yes ment for type of insurance Leape et al. 1999 Clinical Statistical adjust- Retrospective No and labora- ment for type of tory data insurance from medi- cal records Scirica et al. 1999 Clinical Statistical adjust- Prospective Yes ment for type of insurance Canto et al. 1998 Clinical Statistical adjust- Retrospective Yes ment for payor status

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381 B: LITERATURE REVIEW ust for: Disease Assessed Find orbidities? Severity Approriateness Outcomes? Disparities? Yes Yes Yes – no overall Yes, black patients with AMI were differences in equally likely as whites to receive mortality found. beta-blockers, more likely than whites to receive aspirin, but were less likely to receive thrombolytic therapy at time of arrival and were less likely to receive bypass surgery, even when only high-risk coronary anatomic subgroups were assessed. No racial differ- ences in refusal rates for invasive treatment. Yes Yes No Yes, especially when CABG was deemed “necessary.” No Yes No No, only lack of post-high school education was significant predic- tor of underuse. Yes Yes Yes Yes, but diminished with insur- ance eligibility. Yes Yes No Yes, African-American patients less like to undergo CABG than whites, considering RAND criteria. Yes Yes No No significant racial or ethnic differences after accounting for hospital type and necessity of revascularization. No Yes No Yes, among patients meeting criteria for appropriate catheter- ization, fewer nonwhites received catheterization. Yes No Yes Non-African-American minorities less likely to receive beta-blocker TX at discharge, but as likely to receive intravenous thrombolytic therapy (except Asian/Pacific Islanders) and undergo coronary arteriography and revasculariza- tion procedures as whites. No differences in hospital mortality.

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382 UNEQUAL TREATMENT TABLE B-2 Continued Type Prospective/ Adjust for: Disease Author Year of Data Insurance Retrospective Comorbidities? Severity Taylor et al. 1998 Clinical Statistical adjust- Retrospective Yes ment for payor status Laouri et al. 1997 Clinical Not assessed, but Retrospective Yes and labora- patients sampled with patient tory data from both public follow-up from medi- (where patients cal records are likely insured) and private hospi- tals (patients likely uninsured). Maynard et al. 1997 Clinical Statistical adjust- Prospective Yes ment for payment by Medicaid Peterson et al. 1997 Clinical Statistical adjust- Prospective Yes data ment for type of insurance Taylor et al. 1997 Clinical Statistical adjust- Prospective Yes data ment for payment type of insurance

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383 B: LITERATURE REVIEW ust for: Disease Assessed Find orbidities? Severity Approriateness Outcomes? Disparities? Yes No Yes Yes, African Americans less likely to receive intravenous throm- bolytic therapy, coronary arteriog- raphy, and CABG than whites. No differences in hospital mortality. Yes Yes No Yes, significant underuse of revas- cularization procedures among African Americans and patients at public hospitals. Yes No Yes Despite less intensive use of revas- cularization procedures in African Americans, long-term survival after AMI was similar to whites. Yes Yes Yes African Americans less likely than whites to receive bypass surgery, but no differences found in angio- plasty. Differences in treatment most pronounced among patients with severe disease. Differences in treatment associated with lower survival among African Americans. Yes Yes Yes African Americans less likely than whites to receive bypass surgery, but no differences found in angio- plasaty. Differences in treatment most pronounced among patients with severe disease. Differences in treatment associated with lower survival among African Americans.