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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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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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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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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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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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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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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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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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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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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.
Representative terms from entire chapter:
ethnic differences
