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3
MEASURING DISPARITIES IN
HEALTH CARE QUALITY AND
SERVICE UTILIZATION
Thomas A. LaVeist
Over the past century the United States has experienced a
large decline in mortality and enjoyed significant gains in life
expectancy. Yet, while the U.S. has experienced a sustained pattern of
improving health status indicators, disparities in health status among
American racial and ethnic minority groups have persisted. Most
notably, African Americans consistently have the worst health profile
among all major American racial and ethnic groups. As Williams and
Rucker (Williams and Rucker, 2000) demonstrate, the overall Afiican
American mortality rate was sixty percent higher than that of Whites
in 1995. This is precisely what it was in 1950.
While the pattern of racial and ethnic disparities in health has
been well documented and reported, consensual explanations for racial
and ethnic health disparities have been elusive. This is because much
of the published research on racial disparities has focused on
descriptions rather than on explanations (LaVeist, 20001. In the main,
those who have attempted to explain the etiology of health disparities
have provided generalized accounts. There is evidence to support
environmental (Buliard, 1983; Robinson, 1989), social (Lillie-Blanton
et al., 1996; Ren et al., 1999), and behavioral factors (tannin et al.,
1998), as well as factors related to socioeconomic status (Williams and
Collins, 1995~. However, evidence of the contribution of biogenetic
factors is limited and controversial (Bach et al., 2002; Goodman, 2000;
Wood, 2001~. Health care is an additional area that has received
attention as a possible contributor to health status disparities.
A large and growing literature has documented racial and
ethnic disparities in access, utilization, and quality of care (Geiger,
2002; Kressin and Peterson, 2001; Mayberry et al., 2000~. Based in
75
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76 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
part on these persistent findings, the U.S. Congress in 1999 mandated
that the Agency for Healthcare Research and Quality (AHRQ) produce
an annual report on the status of health care disparities, which will be
called the National Healthcare Disparities Report (NHDR). AHRQ
commissioned the Institute of Medicine (IOM) for guidance in
designing the report.
This paper comments on various aspects of the NHDR.
Specifically, this paper will:
Identify major areas in health care services and quality where
racial and ethnic disparities exist;
Identify major areas in health care services and quality where
racial and ethnic disparities are minimal;
Identify the kinds of disparities on which the NHDR should focus;
and
Comment on approaches to reporting health care disparities.
3-1. RACE, ETHNICITY, AND DIFFERENCES IN
HEALTH CARE
The relationship between patient race or ethnicity and health
care services can be placed on a continuum. On one end of the
continuum is health care equality, which can be characterized as health
care services in which the rates of utilization for racial or ethnic
minorities are equal to the rates for comparable White populations. In
the middle are health care disparities, or differences in the rates of
utilization of health care services where racial or ethnic minorities
have substantively Tower rates of utilization. On the other end are what
will be called hyperdisparities, which can be characterized as greater
rates of minority utilization of services that are often less desirable or a
suboptimal pattern of patient service utilization that extends to access
to care. Examples include greater rates of medical errors or limb
amputations for diabetes patients (IOM, 2002~. Other examples of
hyperdisparities are ambulatory care-sensitive hospitalizations (Curler
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3: MEASURING DISPARITIES
77
et al., 1998), missed diagnoses (Pope et al., 2000), and iakogenic
injury (Brennan et al., 199 ~a; Brennan et al., ~ 99 Ib).
Equalities in Health Care Services and Quality
There is a generally acknowledged bias against the publication
of studies that yield "nonfindings." As such, the identification of areas
without racial and ethnic disparities is more difficult than finding areas
where disparities exist. While federal reports are somewhat helpful in
identifying health care equalities, federal data sources in health care
(as opposed to health status) are less so. Because of this, it is important
to note that focusing on the number of identified health care disparities
and hyperdisparities relative to the number of equalities may distort
one's perception of racial and ethnic differences in health care.
However, it is possible to identify several areas of health care equality
even though they are more difficult to find.
Perez-Stable et al. (Perez-Stable et al., 1995) conducted a
telephone survey of Hispanic and White adults, aged 35 to 74 and
living in the San Francisco area, to determine their utilization of
cancer screening tests. The survey found no differences in the use of
fecal occult blood tests, sigmoidoscopy, Pap smears, clinical breast
examinations, and screening mammograms. Additionally, Stafford et
al. (Stafford et al., 1998) examined utilization of hormone replacement
therapy among African American and White patients in the National
Ambulatory Medical Care Survey for 1989 and 1996. This analysis
found that racial disparities in hormone replacement therapy
diminished over time, particularly for women without menopausal
symptoms. However, while the disparity has diminished, there are still
significant differences. The adjusted odds ratio for hormone
replacement in women without menopausal symptoms increased from
0.31 to 0.57, and the adjusted odds ratio among women with
menopausal symptoms increased from 0.3 ~ to 0.86.
Studies that examine a broad array of health conditions are an
additional source of "non-findings." One study examined racial
differences in medical or surgical procedures in the Medicare
population (Escarce et al., 1993). Of the 32 procedures examined, two
(prostatectomy and barium enema) had no significant racial
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78 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
differences. Lee et al. (Lee et al., 1998) also studied Medicare records,
but examined only 18 procedures. Eleven of the 18 procedures were
not associated with disparities (coronary angioplasty, magnetic
resonance imaging (MRI) of the brain, flexible sigmoidoscopy,
colonoscopy, barium enema, total hip replacement, hip repair,
mammogram, mastectomy, and radiation therapy).
Bennett et al. (Bennett et al., 1995) found no significant
differences among African American, Hispanic, and White patients in
the Veterans Administration (VA) for in-hospital mortality rates,
timing of a bronchoscopy, and receipt of timely anti-pneumoniacystis
carinii pneumonia (PCP) medications among HTV/AIDS patients.
Findings such as these in the VA system suggest an interesting
paradox. Studies of the health care system used by active military
personnel have found no racial and ethnic disparities in care (Dominitz
et al., 1998; Taylor et al., 1997~. However, some studies of the VA
system, which is used by former military personnel, have documented
racial disparities (Peterson et al., 1994; Whittle et al., 1993~. One
plausible explanation for this is that the active duty health care system,
including health care providers and patients, is part of a broad military
culture tightly controlled by a chain of command that frowns on race-
based distinctions. By contrast, the VA system is less closely
associated with the active military. As such, its providers (and
patients) are civilians. Therefore, they are influenced by social and
cultural factors similar to other health care settings. Further
exploration of racial disparities in the VA system compared with the
active military system may be fruitful in understanding the etiology of
racial disparities in health care.
Disparities in Health Care Services and Quality
Racial and ethnic differences in access and utilization of
health services comprise the largest category of studies of disparities
in health care. After controlling for numerous individual factors, Shi
(Shi, 1999) showed that minority populations were 1.46 times more
likely to identify their usual source of care as a facility rather than a
person. In addition, minorities in general and Hispanics in particular
were less likely than Whites to indicate that their usual care providers
listened to them. Cornelius and Collins (Cornelius and Collins, 2000)
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3: MEASURING DISPARITIES
79
found substantial differences by race and ethnicity in health insurance
status and having a usual source of care. Blendon et al. (Blendon et al.,
1989) found racial differences in access to care across all income
groups and demonstrated severe underuse of services among African
Americans.
If racial and ethnic disparities in health status are to be
eliminated, access and availability of health care are major
considerations. These issues are largely related to differences in
socioeconomic status among racial and ethnic groups and the
continuation of public policies that link health insurance to
employment or citizenship. However, the problem of racial and ethnic
disparities in health care extends beyond access to health care
facilities. It also includes disparities in the availability of health care
resources in the facilities where racial and ethnic minorities receive
care. As indicated in Unequal Treatment (TOM, 2002), there is a large
literature demonstrating racial and ethnic disparities in access to
specific medical procedures after patients have entered the health care
system. This literature is a diverse amalgam of studies documenting
disparities in primary care (Moore et al., 1994), specialty care
(McAlpine and Mechanic, 2000), surgical procedures (Escarce et al.,
1993; Lee et al., 1998; McBean and Gornick, 1994), and inpatient
education (Cowie and Harris, ~ 997~.
In 2000 Mayberry and associates published a comprehensive
review of the literature on racial disparities in health care, focusing on
studies published between 1985 and 1999 (Mayberry et al., 2000~. The
article summarized a large number of studies documenting disparities
across a wide variety of health conditions. Disparities were
documented in health services for heart disease, stroke, cancer,
diabetes, HIV/AIDS, prenatal care, immunizations, asthma, and
mental health services. The conditions studied by Mayberry et al.
conform to the major health conditions examined in the Report of the
Secretary's Task~force or' Black and Minority Health (DHHS, 1985~.
Others have reviewed the literature as it relates to specific conditions
and procedures. For example, Homer et al. (Homer et al., 1995)
reviewed the literature on race disparities in health care for stroke
patients, and Sheifer et al. (Sheifer et al., 2000) examined studies of
racial disparities in access to coronary angiography. And still others
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80 GUIDANCE FOR THE NATIONAE HEALTH CARE DISPARITIES REPORT
conducted studies of disparities across numerous procedures to test for
those that demonstrated major disparities compared to those that did
not (Escarce et al., 1993; Lee et al., 1998; McBean and Gornick,
1994).
To identify documented areas in health care with the greatest
and least health disparities, each of these types of reviews was
examined. The results of this examination of the literature are
summarized in Table 3-~. Table 3-l reports selected studies of areas
of health care with the largest and best-documented disparities.
The best-documented disparities in health care may be those
that relate to procedures for cardiovascular disease. Coronary
angiography is a procedure of particular importance. Heart disease is
the leading cause of death in the United States, and coronary
angiography is essentially a prerequisite for percutaneous transluminal
coronary angioplasty (PTCA) or coronary bypass surgery. Perhaps
most striking is the finding of racial disparities in the use of coronary
angiography within the VA (Peterson et al., 1994; Sedlis et al., 1997~.
This is because access to care is similar for all, and there is no
economic incentive for either the patient or the provider related to
care.
Cancer is also a condition with a large number of documented
disparities in the quality of care. For example, Burns et al. (Burns et
al., 1996) found that African American women were less likely than
White women to receive mammography even after adjusting for use of
primary care. Cooper et al. (Cooper et al., 1996) found that a higher
proportion of White colorectal cancer patients (78 percent) underwent
surgical resection than their African American counterparts (68
percent). Earie et al. (EarIe et al., 2002) found disparities in race and
socioeconomic status in referral patterns for chemotherapy among
lung cancer patients. And Harlan et al. (Harlan et al., 1991) found that
Hispanic women were less likely to receive Pap smears than White
women.
1 It should be noted that variability across sample populations, settings, and
databases in the studies reviewed can affect overall conclusions and
generalizations on racial and ethnic health care disparities.
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3: MEASURING DISPARITIES
81
Other procedures related to major causes of death and/or
disability include diagnostic and therapeutic procedures for
cerebrovascular disease (Eggers, 1995; Homer et al., 1995), renal
transplantation (Epstein et al., 2000), HIV antiretroviral therapy
(Moore et al., 1994), asthma (All and Osberg, 1997), and participation
in AIDS clinical trials (Stone et al., 1997~. Marsh et al. (Marsh et al.,
1999) found that physicians were twice as likely to recommend
hormone replacement therapy for White patients than Blacks. And
Todd et al. (Todd et al., 2000) demonstrated that 43 percent of African
American patients with extremity fractures at one university hospital
went untreated for pain, while only 26 percent of White patients with
similar fractures went untreated. A similar study by Todd et al. (Todd
et al., 1993) found that White patients with broken bones were 64
percent more likely to receive pain medication than Hispanic patients
with similar fractures.
Additionally, in a recently published article, Edelstein
(Edelstein, 2002) documented continuing disparities in dental health
care. This is consistent with national reports showing disparities in
untreated caries for African Americans and Hispanics compared with
Whites (Eberhart et al., 2001~. Gornick's (Gornick, 2000) study of
trends in racial differences in receipt of selected health care procedures
among Medicare recipients showed that ten of the thirteen procedures
examined exhibited increasing disparities over time. Two procedures
showed decrease and one disparity remained the same.
It can be concluded from studies of racial and ethnic
differences in access and utilization of health services that racial and
ethnic minorities often face the prospect of seeking care in facilities
with fewer resources. And, when they obtain access to similar
facilities, they often receive less optimal treatment than nonminorities.
OCR for page 82
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84 GUIDANCE FOR THE NATIONAL HEALTHCARE DISPARITIES REPORT
Hyperdisparities in Health Care Services and Quality
In an update of a 1996 study, Gornick (Gornick, 2000)
examined trends in racial differences in the use of health services by
Medicare beneficiaries during the 1990s. Gornick (Gornick, 2000)
demonstrated three hyperdisparities: amputation of the lower limb,
arteriovenostomy, and excisional debridement. One set of analyses
(see Table 3-2 for information on some analyses) found that, in each
case, the disparities actually increased between 1986 and 1994.
McBean and Gornick (McBean and Gornick, 1994) found that
bilateral orchiectomy was also more commonly used in African
American patients. The ratio of Blacks to Whites was I .57 in 1986 and
2.47 in 1992.
TABLE 3-2 Hyperdisparities among Medicare Enrollees Age 65 and Over
BLAC K/WHITE BLAC K/WHITE 1994- 198 6
PROCEDURE RATIO OF RATIO OF HYPERDISPARITY
R A T E S : R ~ T E S : D I F F E R E N C E
1986 1994
Amputation of 3.24 3.47 .23
Lower Limb
A r t e r i o v e n o s t o m y 4 . 0 2 4 . 5 3 . 5 1
Excisional 2.36 2.51 .15
Debridement
SOURCE: (Go~nick, 20001.
Culler et al. (Curler et al., 1998) examined Medicare
administrative records to identify patient characteristics associated
with potentially preventable hospitalizations and found that Afiican
American patients were more likely to have such hospitalizations.
Brennan et al. (Brennan et al., ~ 99 ~ a; Brennan et al., ~ 991b) found that
hospitals that serve primarily minority patients have similar rates of
adverse events compared to those hospitals that do not treat
predominantly minority populations. Yet these same hospitals have
significantly higher rates of adverse events due to medical negligence
or errors compared to those hospitals not treating predominantly
minority patients. Even after controlling for hospital characteristics
and for disease severity and complexity, the only factor that remains
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3: MEASURING DISPARITIES
85
consistently associated with an increased risk of adverse events due to
negligence is a large proportion of discharged minority patients.
3-2. CREATING A NATIONAL HEALTHCARE
DISPARITIES REPORT
There are numerous factors to consider in determining the
types of disparities that should be the focus of the NHDR. Since the
report will need to rely on existing data sources (at least in the short
term), this presents a set of limitations that may hinder the utility of
the report. Many existing data sources can be used to adequately
measure morbidity, mortality, and health risks such as smoking and
obesity. However, there are fewer national databases that can be used
to measure health care indicators. The Centers for Medicare and
Medicaid Services (CMS) offer a good source of data on health care
disparities among the elderly. Similarly, the Medical Expenditure
Panel Survey (MEPS), the Healthcare Cost and Utilization Project
(HCUP), and the National CAMPS (Consumer Assessment of Health
Plans) Benchmarking Database (NCBD) are all potential sources of
data, at least in the short term. But sources of national data on
disparities in underuse or overuse of specific medical procedures for
non-Medicare or Medicaid populations are still more limited.
in establishing criteria for the selection of measures for the
NHDR, there are a variety of factors to consider. One might select
procedures with the highest costs or those that are the most thoroughly
documented. One might also select procedures associated with
conditions with the highest mortality rates or the greatest number of
years of potential life lost. However, these approaches are somewhat
problematic. Years of potential life lost would tend to select causes of
death for younger Americans such as nonchronic conditions and
homicides, accidents, and injuries. These are important, but tertiary
considerations. Rather, a conceptual framework should be used that
combines the continuum of health care disparities (equalities,
disparities, and hyperdisparities) with the four consumer perspectives
on health care needs, as discussed in Envisioning the National
Healthcare Quality Report (IOM, 2001~. The continuum of disparities
would range from equality, or the absence of disparities; to disparities,
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88 GUIDANCE FOR THE NATIONAL HEALTHCARE DISPARITIES REPORT
1989), glaucoma (Iavitt et al., 1991), and psychiatric conditions
(Chung et al., ~ 995~.
Health Status Outcomes
A growing body of health care quality data suggests that
iatrogenic injury should be considered an important component of the
total quality of care picture. The literature indicates that a significant
proportion of adverse events are due to errors in medical judgment that
result in delivered care that is Tower than commonly accepted medical
standards. Those events that result in significant disability, morbidity,
and/or mortality to the patient are by definition said to be due to
negligence (Brennan et al., l99la; Brennan et al., 199lb). HCUP
(although geographically limited) is an example of data that can be
used to produce estimates of components of health care quality from
hospital discharge data.
Approaches to Reporting
It is important that the data are reported in a way that is
accessible to policy makers and the general public. The U.S.
Department of Labor produces a set of economic indicators that is
closely watched and widely regarded as a gauge of the economic status
of the country (for example, the Consumer Price Index, the
Employment Cost Index, the Employment Situation, the Producer
Price Index, Productivity and Costs, Real Earnings, and the U.S.
Import and Export Price Indexes). It is possible to create such
measures for health status, health care quality, and disparities that
could serve as "the health disparities index." There is some
experience with such measures in health, including the World Health
Organization's "Global Burden of Disease" project. One undesirable
aspect of "global measures" is that it is inevitable that they will mask
some degree of variability (Nygaard, 2000~. However, such a measure
would be a valuable toot in informing the public and policy makers.
An advantage of global measures is that they provide a summary
statistic that is reflective of the general pattern of health care
disparities, thereby avoiding details that may be unnecessary for policy
makers and others to consider.
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3: MEASURING DISPARITIES
89
The specific computation of such an index is beyond the scope
of this paper. It would be valuable to invest some resources in the
creation of a set of global measures of health care disparities . These
measures would aid in monitoring progress in improving the nation's
health in general and eliminating health care disparities specifically.
Additionally, such measures would eliminate the need to establish one
racial and ethnic group (typically Whites) as a standard against which
other groups are compared. The race-comparative approach has
several undesirable aspects (as will be described below).
The standard formats of reporting disparities used in health
care research include risk ratios, odds ratios, and difference scores.
Each of these methods has disadvantages. Table 3 - presents
simulated data on use of cardiac catheterization among 250 Afiican
American and White patients who were appropriate candidates for the
procedure.
To calculate the risk ratio (also called the rate ratio or ratio of
rates), one would compute the ratio of the percentage of patients in
each group who received catheterization. Thus
Risk Ratio=.33 . 57.=.58
This statistic represents the risk of receiving catheterization
for African Americans relative to Whites. However, it does not
account for the possibility of overutilization of the procedure among
Whites.
TABLE 3-4 Simulated Data
RECEIPT OF CARDIAC PATIENT PATIENT
CATHETERIZATION RACE: RACE: TOTAL
BLACK WHITE
No. of Patients 75 175 250
No. Receiving Procedure 25 100 125
TO Receiving Procedure 33°/O \. 57% 50%
Predicted % of Cardiac 30% 70% 100%
Catheterizations Received by Group
Observed % of Cardiac 20% 80% 100%
Catheterizations Received by Group
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90 GUIDANCE FOR THE NATIONAL HEALTHCARE DISPARITIES REPORT
A second standard approach is to compute the odds ratio. This
statistic is computed by taking the ratio of the odds of receiving
catheterization for one group relative to the other. Thus, the odds of
receiving catheterization for African Americans are 25 . 50 = .5 and
the odds for Whites are 100 - 75 = 1.33. The odds ratio is .5 . 1.33 =
.38. This statistic represents the degree of disparity in the relative odds
of getting catheterization. Like the risk ratio, it expresses disparity
relative to Whites.
A third approach is to take the simple difference in
percentages for each group. Thus, 57 percent of Whites receive a
procedure compared to 33 percent of African Americans: 57 - 33 = 24.
A limitation to each of these approaches (besides again Using
one group as the standard) is that the magnitude of the difference is not
changed by qualitative differences in the rates. For example, 25 -1 =
24. Also, 100 - 76 = 24.
.
One approach to consider is the ratio of health care inequality.
This statistic can be computed by first computing predicted and
observed percentages of catheterization received by each group. This
can be done as follows: determine the number of total patients that
African Americans and Whites represent (75 - 250 = .3 X 100 = 30
percent for African Americans. For Whites, 175 . 250 = .7 X 100 = 70
percent). Since African Americans comprise 30 percent of the patients
who need the procedure, one would expect they would receive 30
percent of the catheterizations. The degree to which the predicted
percentage of catheterization deviates from the observed percentage
indicates the degree of disparity in obtaining health care resources that
were expended. Thus the ratio is produced by computing the ratio of
observed to predicted catheterizations. For African Americans, 20 . 30
= .67, and for Whites, 80 - 70 = 1.14. It can be said, therefore, that
African Americans received 67 percent of the catheterizations that
they should have received, and Whites received 14 percent more than
their share. This approach can be used to produce a unique score for
each group, including Whites. Also, the score is easily understood. A
score of 1 can be interpreted as equilibrium between observed and
expected utilization. A score greater than 1 indicates that the procedure
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3: MEASURING DISPARITIES
91
is used in the group more than one would expect given a colorblind
allocation of resource.
3-3. CONCLUSION
This paper has presented issues for consideration in the
development of the National Health Disparities Report. The
considerations are summarized by the following suggestions. Create a
framework for the categorization of health disparities that includes the
continuum of health care equalities, disparities, and hyperdisparities as
well as the four consumer perspectives on health care needs: staying
healthy, getting better, living with illness or disability, and coping with
the end of life (IOM, 2001~. In addition, adopt a set of criteria to use in
the selection of individual measures. Criteria suggested include
applicability to multiple racial and ethnic groups; accessibility to a
broad population of health care consumers; limited confounding; and
replicability.
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92 GUIDANCE FOR THE NATIONAL HEAETHCARE DISPARITIES REPORT
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Representative terms from entire chapter:
care disparities
