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1
Introduction and Literature Review
Despite steady improvement in the overall health of the U.S. popula-
tion, racial and ethnic minorities, with few exceptions, experience higher
rates of morbidity and mortality than non-minorities. African Americans,
for example, experience the highest rates of mortality from heart disease,
cancer, cerebrovascular disease, and HIV/AIDS than any other U.S. racial
or ethnic group. American Indians disproportionately die from diabetes,
liver disease and cirrhosis, and unintentional injuries. Hispanic Ameri-
cans are almost twice as likely as non-Hispanic whites to die from diabe-
tes. In addition, some Asian-American subpopulations experience rates
of stomach, liver, and cervical cancers that are well above national aver-
ages. The reasons for these health status disparities are complex and
poorly understood, but may largely reflect socioeconomic differences, dif-
ferences in health-related risk factors, environmental degradation, and
direct and indirect consequences of discrimination (Williams, 1999).
Differences in access to healthcare are also likely to play a role in these
health disparities. Hispanics, Asian Americans, American Indians and
Alaska Natives, and African Americans are less likely than whites to have
health insurance, have more difficulty getting healthcare, and have fewer
choices in where to receive care. Hispanic and African-American patients
are also more likely to receive care in hospital emergency rooms, and are
less likely than whites to have a regular primary care provider (Collins,
Hall, and Neuhaus, 1999).
Concern is growing, however, that even at equivalent levels of access
to care, racial and ethnic minorities experience a lower quality of health
services and are less likely to receive even routine medical procedures
29
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30 UNEQUAL TREATMENT
than white Americans. For example, relative to whites, African Ameri-
cans and Hispanics are less likely to receive appropriate cardiac medica-
tion (e.g., thrombolytic therapy, aspirin and beta blockers) or to undergo
coronary artery bypass surgery, even when variations in such factors as
insurance status, income, age, co-morbid conditions, and symptom ex-
pression are taken into account (Ayanian et al., 1993; Hannan et al., 1999;
Ramsey et al., 1997; Johnson et al., 1993; Canto et al., 2000). African Ameri-
cans with end-stage renal disease are less likely to receive peritoneal di-
alysis and kidney transplantation (Kasiske, London, and Ellison, 1998;
Barker-Cummings, McClellan, Soucie, and Krisher, 1995; Gaylin et al.,
1993), and African-American and Hispanic patients with bone fractures
seen in hospital emergency departments are less likely than whites to re-
ceive analgesia (Todd et al., 2000; Todd, Samaroo, and Hoffman, 1993). In
terms of quality of care, a recent study of Medicare patients revealed that
African-American patients with congestive heart failure or pneumonia
received poorer quality care than whites, using explicit process criteria
and implicit review by physicians (Ayanian, Weissman, Chasen-Taber,
and Epstein, 1999). Further, these differences are associated with greater
mortality among African-American patients (Peterson et al., 1997).
STUDY CHARGE AND COMMITTEE ASSUMPTIONS
These disparities prompted Congress in 1999 to request an Institute of
Medicine (IOM) study to assess disparities in the kinds and quality of
healthcare received by U.S. racial and ethnic minorities and non-minori-
ties. Specifically, Congress requested that the IOM:
• Assess the extent of racial and ethnic differences in healthcare that
are not otherwise attributable to known factors such as access to care (e.g.,
ability to pay or insurance coverage);
• Evaluate potential sources of racial and ethnic disparities in health-
care, including the role of bias, discrimination, and stereotyping at the
individual (provider and patient), institutional, and health system levels;
and
• Provide recommendations regarding interventions to eliminate
healthcare disparities.
In its interpretation of the charge, the study committee assumes re-
sponsibility for assessing variation in the quality of healthcare services
provided to individuals of different racial and ethnic backgrounds, inde-
pendently of patients’ insurance status, education, income, or other fac-
tors that are known to affect access to care. This is a somewhat artificial
and difficult distinction, as many access-related factors, such as the type
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INTRODUCTION AND LITERATURE REVIEW
of health insurance coverage that healthcare consumers purchase or are
provided, as well as their level of education and other unmeasured as-
pects of socioeconomic status (e.g., assertiveness in seeking care) signifi-
cantly affect the quality and intensity of healthcare that they receive, and
are highly correlated with race and ethnicity. The relationship of these
variables to healthcare quality is therefore highlighted where appropriate
in this report. For purposes of addressing the study charge, however, the
committee’s focus extends only to the direct and indirect effects of race
and ethnicity in the process, structure, and outcomes of healthcare.
Further, the committee assumes that healthcare refers to the continuum
of services provided in traditional healthcare settings—including public
and private clinics, hospitals, community health centers, nursing homes,
and other healthcare facilities—as well as home-based care. These in-
clude services provided by a range of healthcare professionals, including
physicians, nurses, physician assistants, psychologists, and other licensed
professionals. The term healthcare services refers to the provision of pre-
ventive, diagnostic, rehabilitative and/or therapeutic medical or health
services to individuals or populations. Quality of care refers to the degree
to which health services for individuals and populations increase the like-
lihood of desired health outcomes and are consistent with current profes-
sional knowledge. These definitions, and their interrelationship, are best
summarized in the 1999 IOM report, Measuring the Quality of Health Care:
The IOM stated . . . that “quality of care is the degree to which health
services for individuals and populations increase the likelihood of de-
sired health outcomes and are consistent with current professional
knowledge” (IOM, 1990, p. 21). This definition has been widely accepted
and has proven to be a robust and useful reference in the formulation of
practical approaches to quality assessment and improvement
(Blumenthal, 1996). Several ideas in this definition deserve elaboration.
The term health services refers to a wide array of services that affect health,
including those for physical and mental illnesses. Furthermore, the defi-
nition applies to many types of healthcare practitioners (physicians,
nurses, and various other health professionals) and to all settings of care
(from hospitals and nursing homes to physicians’ offices, community
sites, and even private homes). . . .
The inclusion in the definition of both populations and individuals draws
attention to the different perspectives that need to be addressed. On the
one hand, there is concern with the quality of care that individual organi-
zations, health plans, and clinicians deliver. On the other hand, attention
must be paid to the quality of care across the entire system. In particular,
one must ask whether all parts of the population have access to needed
and appropriate services, whether services meet or exceed their expecta-
tions, and whether their health status is improving. That focus embraces
all groups, whether or not they have access to care and whether they are
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32 UNEQUAL TREATMENT
defined by cultural heritage, sociodemographic characteristics, geogra-
phy (e.g., a state or a region), or diagnosis. It recognizes that such indi-
viduals will include the most vulnerable, whether the source of vulner-
ability is economic, the rarity or severity of the health problem, physical
frailty, or physical or emotional impairment. (Institute of Medicine,
1999a; emphasis in text).
The study committee defines disparities in healthcare as racial or eth-
nic differences in the quality of healthcare that are not due to access-re-
lated factors or clinical needs, preferences,1 and appropriateness of inter-
vention (Figure 1-1). The committee’s analysis is focused at two levels: 1)
the operation of healthcare systems and the legal and regulatory climate
in which health systems function; and 2) discrimination at the individual,
patient-provider level. Discrimination, as the committee uses the term,
refers to differences in care that result from biases, prejudices, stereotyp-
ing, and uncertainty in clinical communication and decision-making. It
should be emphasized that these definitions are not legal definitions. Dif-
ferent sources of federal, state and international law define discrimination
in varying ways, some focusing on intent and others emphasizing dispar-
ate impact.
Finally, in defining racial and ethnic minority groups, the committee uses
the definitions provided by the federal Office of Management and Budget
in its proposed Revisions to the Standards for the Classification of Federal
Data on Race and Ethnicity (Office of Management and Budget, 2001).
The revised standards (see Box 1-1) establish five categories for “racial”
groups (American Indian or Alaska Native, Asian, Black or African
American, Native Hawaiian or other Pacific Islander, and White), and two
categories for “ethnic” groups (Hispanic or Latino and Not Hispanic or
Latino).2 It should be noted that these definitions have been subject to
considerable criticism, including:
1The committee defines patient preferences as patients’ choices regarding healthcare that
are based on a full and accurate understanding of treatment options. As discussed in Chap-
ter 3 of this report, patients’ understanding of treatment options is often shaped by the
quality and content of provider-patient communication, which in turn may be influenced by
factors correlated with patients’ and providers’ race, ethnicity, and culture. Patient prefer-
ences that are not based on a full and accurate understanding of treatment options may
therefore be a source of racial and ethnic disparities in care. The committee recognizes that
patients’ preferences and clinicians’ presentation of clinical information and alternatives in-
fluence each other, but found separation of the two to be analytically useful.
2Consistent with the OMB classification scheme, the terms “African American” and
“black” are used interchangeably throughout this report, as are the terms “Hispanic” and
“Latino.”
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INTRODUCTION AND LITERATURE REVIEW
Clinical Appropriateness
and Need
Patient Preferences
Difference The Operation of
Quality of Health Care
Healthcare Systems and
Non-Minority
Legal and Regulatory
Climate
Disparity
Discrimination:
Minority
Biases, Stereotyping,
and Uncertainty
FIGURE 1-1 Differences, disparities, and discrimination: Populations with equal
access to healthcare. SOURCE: Gomes and McGuire, 2001.
• reinforcement of the concept of “race” as reflecting genetic or bio-
logic differences between population groups;
• failure to reflect the fluid and dynamic nature of sociopolitical iden-
tity, and
• failure to reflect the way many Americans choose to define them-
selves (Institute of Medicine, 1999b).
Nonetheless, the committee adopts these racial and ethnic definitions
because they are commonly accepted among researchers, and most feder-
ally funded research utilizes these terms. Further, as will be noted below,
access to and the allocation of healthcare resources differ with striking
consistency across these population groups, making them useful in track-
ing disparities in care.
To summarize, racial and ethnic minorities are less likely than whites
to posses health insurance (Collins, Hall, and Neuhaus, 1999), are more
likely to be beneficiaries of publicly funded health insurance (e.g., Medic-
aid [The Henry J. Kaiser Family Foundation, 2000b]), and even when
insured, may face additional barriers to care due to other socioeconomic
factors, such as high co-payments, geographic factors (e.g., the relative
scarcity of healthcare providers and healthcare facilities in minority com-
munities), and insufficient transportation. These access-related factors are
likely the most significant barriers to equitable care, and must be addressed
as an important first step toward eliminating healthcare disparities. The
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34 UNEQUAL TREATMENT
BOX 1-1
Revised Standards for the Classification of Federal Data on
Race and Ethnicity
Categories for Race:
American Indian or Alaska Native. A person having origins in any of the
original peoples of North and South America (including Central America),
and who maintains tribal affiliation or community attachment.
Asian. A person having origins in any of the original peoples of the Far
East, Southeast Asia, or the Indian subcontinent including, for example,
Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam.
Black or African American. A person having origins in any of the black
racial groups or Africa. Terms such as “Haitian” or “Negro” can be used in
addition to “Black or African American.”
Native Hawaiian or Other Pacific Islander. A person having origins in any
of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White. A person having origins in any of the original peoples of Europe,
the Middle East, or North Africa.
Categories for Ethnicity:
Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or
Central American, of other Spanish culture or origin, regardless of race.
The term “Spanish origin” can be used in addition to “Hispanic or Latino.”
Not Hispanic or Latino.
SOURCE: Office of Management and Budget, 2001.
committee is asked, however, to assess whether other factors may con-
tribute to health-care disparities once these “threshold” factors (i.e., racial
and ethnic differences in income, health insurance status, and geography)
are held constant, and to specifically address whether bias, discrimination,
or stereotyping at the individual, institutional, and health systems levels
may explain some part of these disparities. To a great extent, attempts to
separate the relative contribution of these factors risks presenting an
incomplete picture of the complex interrelationship between racial and
ethnic minority status, socioeconomic differences, and discrimination in
the United States. For example, as will be discussed in Chapter 2, racial
and ethnic housing segregation is a by-product of both historic and con-
temporary racism and discrimination, as well as socioeconomic differ-
ences (itself the legacy of poorer opportunities for many minority groups).
The committee therefore stresses that attempts to “parcel out” access-
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INTRODUCTION AND LITERATURE REVIEW
related factors from the quality of healthcare for minorities remains an
artificial exercise, and that policy solutions must consider the historic and
contemporary forces that contribute to differences in access to and quality
of healthcare.
THE RELATIONSHIP BETWEEN RACIAL AND ETHNIC
DISPARITIES IN HEALTH STATUS AND HEALTHCARE
The health gap between minority and non-minority Americans has
persisted, and in some cases, has increased in recent years. African-
American men, for example, experienced an average life expectancy of 61
years in 1960, compared with 67 years for their white male peers; in 1996,
this gap increased to 8 years, as white males enjoyed an average life ex-
pectancy of 74 years, relative to 66 years for African-American males.
American-Indian men in some regions of the country can expect to live
only into their mid-fifties. Further, African-American and American-In-
dian infant mortality rates remain approximately 2.5 and 1.5 times higher,
respectively, than rates for whites (Collins, Hall, and Neuhaus, 1999).
As noted above, the reasons for these health status disparities are com-
plex. Individual risk factors for poor health are pronounced among many
racial and ethnic minorities, yet these risks are confounded by the dispro-
portionate representation of minorities in the lower socioeconomic tiers.
Moreover, socioeconomic position in and of itself is correlated with health
status, independently of individual risk factors, as people in each ascend-
ing step along the socioeconomic gradient tend to have better health, even
when individual health risk factors are accounted for (Kaplan, Everson,
and Lynch, 2000). Cultural factors also play an important role in health
disparities; among some immigrant Hispanic populations, for example,
birth outcomes have been found to be better than among those of their
U.S.-born peers, suggesting that sociocultural risk increases with subse-
quent generations living in the United States (Korenbrot and Moss, 2000).
Further, environmental health risks, such as degradation, air, water, and
soil pollution, and other physical health hazards are more prevalent in
low-income racial and ethnic minority communities. These and other risk
factors associated with health and poor health illustrate that racial and
ethnic disparities in health status largely reflect differences in social, so-
cioeconomic, and behavioral risk factors and environmental living condi-
tions (House and Williams, 2000). Healthcare is therefore necessary but
insufficient in and of itself to redress racial and ethnic disparities in health
status (Williams, 1999). A broad and intensive strategy to address socio-
economic inequality, concentrated poverty in many racial and ethnic mi-
nority communities, inequitable and segregated housing and educational
facilities, individual behavioral risk factors, as well as disparate access to
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36 UNEQUAL TREATMENT
and use of healthcare services is needed to seriously address racial and
ethnic disparities in health status.
WHY ARE RACIAL AND ETHNIC DISPARITIES
IN HEALTHCARE IMPORTANT?
The preceding discussion should not be interpreted as suggesting that
racial and ethnic disparities in healthcare are unimportant, either to indi-
viduals in need of care or to a society that prides itself on equality of
opportunity. To the contrary, disparities in healthcare are problems that
have significant implications for health professionals, administrators and
policymakers, and healthcare consumers of all backgrounds.
For the health professions, racial and ethnic disparities in healthcare
pose moral and ethical dilemmas that will be among the most significant
challenges of today’s rapidly changing health systems. Increasingly, phy-
sicians and other health professionals are faced with a complex set of soci-
etal expectations. On one hand, they are expected to adhere to the highest
ethical standards of service that mandate fairness and compassion. On
the other hand, physicians are placed in the position of serving as manag-
ers of vital, yet limited healthcare resources. Their decisions may result in
the allocation of more resources to some individuals than to others, re-
sulting in the unequal distribution of healthcare across population groups.
These challenges occur in the context of increasing financial and bureau-
cratic pressures on healthcare providers, which may exacerbate the prob-
lem of inequitable care. Yet the public’s trust in the health professions
may be irrevocably harmed should the healthcare industry be engaged,
even inadvertently, in “social triaging.” It is vitally important to preserve
this trust, which is already fragile in many racial and ethnic minority com-
munities, as it can significantly affect patients’ willingness to seek care
and adhere to treatment regimens.
Health professionals and policymakers must also be cognizant of the
importance of healthcare as a resource that is tied to social justice, oppor-
tunity, and the quality of life for individuals and groups. The productiv-
ity of the workforce is closely linked with its health status, yet if some
segments of the population, such as racial and ethnic minorities, receive a
lower quality and intensity of healthcare, then these groups are further
hindered in their efforts to advance economically and professionally. It is
therefore important from an egalitarian perspective to expect equal per-
formance in healthcare, especially for those disproportionately burdened
with poor health.
From a public health standpoint, racial and ethnic disparities in
healthcare threaten to hamper efforts to improve the nation’s health. As
will be discussed in Chapter 3, the United States is becoming increasingly
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INTRODUCTION AND LITERATURE REVIEW
diverse; while white Americans currently constitute 71% of the popula-
tion, by the year 2050 nearly one in two Americans will be a person of
color (U.S. Bureau of the Census, 2000). These groups, as noted earlier,
experience a poorer overall health status and lower levels of access to
heathcare than white Americans, and experience a disproportionate bur-
den of chronic and infectious illness. This higher burden of disease and
mortality among minorities has profound implications for all Americans,
as it results in a less healthy nation and higher costs for health and reha-
bilitative care. All members of a community are affected by the poor
health status of its least healthy members—infectious diseases, for ex-
ample, know no racial/ethnic or socioeconomic boundaries. For this rea-
son, the federal Healthy People 2010 initiative has established an overarch-
ing goal of eliminating health disparities, noting that “the health of the
individual is almost inseparable from the health of the larger community,
and . . . the health of every community in every State and territory deter-
mines the overall health status of the Nation” (U.S. Department of Health
and Human Services, 2000a, p. 15).
From an economic standpoint, the costs of inadequate care may have
significant implications for overall healthcare expenditures. Poorly man-
aged chronic conditions or missed diagnoses can result in avoidable,
higher subsequent healthcare costs. For example, inadequately treated
and managed diabetes can result in far more expensive complications,
such as kidney disorder requiring dialysis or transplantation. To the ex-
tent that minority beneficiaries of publicly funded health programs are
less likely to receive high quality care, these beneficiaries—as well as the
taxpayers that support public healthcare programs—may face higher fu-
ture healthcare costs.
Further, the problem of racial and ethnic disparities in healthcare
poses a significant dilemma for a society that is still wrestling with a legacy
of racial discrimination (Byrd and Clayton, this volume). Public opinion
polls indicate that the vast majority of Americans abhor any form of racial
discrimination and believe that all Americans should—and do—enjoy
equal opportunities in accessing educational and job opportunities, as well
as healthcare (Morin, 2001). Yet this ideal falls far from reality in many
sectors of American life, including healthcare, as will be discussed in later
sections of this report. The discrepancy between Americans’ widely held
values and beliefs regarding the importance of equality and the reality of
persistent racial inequities tears at the social fabric of the nation and con-
tributes to the gulf of understanding between racial, ethnic and socioeco-
nomic groups.
Finally, for the population at large, racial and ethnic disparities in
healthcare raise concerns about the overall quality of care in the United
States. Given that racial and ethnic minority groups experience greater
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38 UNEQUAL TREATMENT
challenges and barriers to high quality care, their experiences expose
healthcare systems’ greatest weaknesses and problems—problems that
any American may face in attempting to access healthcare. In this con-
text, the extent to which minorities are well or poorly served provides an
important indicator of the state of healthcare in the nation. The provision
of equitable care that does not vary by patient race, ethnicity, gender, and
age is therefore among one of the six overarching goals identified in the
Institute of Medicine’s Crossing the Quality Chasm report (IOM, 2001a). As
the Chasm report suggests, evidence of unequal or substandard care for
some segments of the population, particularly on the basis of group mem-
bership, should raise the concern that the provision of care may be incon-
sistently and subjectively administered. Inequities in care, therefore, ex-
pose a threat to quality care for all Americans.
For all of these reasons, should evidence be available to suggest that
racial and ethnic disparities in care are widespread, these disparities
would be unacceptable.
EVIDENCE OF RACIAL AND ETHNIC
DISPARITIES IN HEALTHCARE
The literature review that follows summarizes articles published in
peer-reviewed journals within the last 10 years, with an emphasis on the
most recent publications. In selecting literature to review, the committee
identified studies that assess racial and ethnic variation in healthcare while
controlling for differences in access to healthcare (e.g., by studying simi-
larly insured patients or by statistically adjusting for differences in insur-
ance status) and/or socioeconomic status. 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 at-
tempted to assess variations in care by patient socioeconomic status and
geographic region. These studies were included if the researchers as-
sessed racial or ethnic differences in care while controlling, as noted above,
for patient access-related factors. In addition, the committee focused its
review on those studies that attempt to assess the contribution of a range
of other potential confounding variables, such as racial and ethnic differ-
ences in disease severity, stage of illness progression, patient preferences
for non-invasive procedures or to avoid complex treatments, types of set-
tings where care is received (e.g., public vs. private clinics, teaching vs.
non-teaching hospitals), availability of procedures (e.g., whether catheter-
ization is offered on-site), suitability of intervention (e.g., whether subtle
racial differences in response to treatments may counter-indicate use), as
well as other factors. Further, the committee paid particular attention to
studies that assessed the appropriateness of services relative to established
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INTRODUCTION AND LITERATURE REVIEW
clinical guidelines. To the extent that these studies shed light on potential
sources of disparities in care, they are summarized in this review. The
committee’s criteria for selecting literature to review are listed in Box 1-2.
Almost all of the studies reviewed by the committee contained one or
more weaknesses of study design, methodology, or data analysis that lim-
ited the committee’s ability to draw findings and conclusions. These
weaknesses are noted below, where appropriate. The majority of studies
of racial and ethnic disparities in care, for example, use odds ratios, which
is a consequence of using logistic regression models, rather than risk ra-
tios to assess the extent of disparities in care. Relative to risk ratios, odds
ratios exaggerate the apparent effect of a co-variable when the prevalence
of the dependent variable is above 5%-10%. The committee therefore cau-
tions that in some instances, the magnitude of racial and ethnic disparities
as reported in the literature may be exaggerated. In addition, as will be
discussed below, no single study adequately controlled for all potential
confounding factors (e.g., patient preferences, racial differences in disease
severity or presentation, geographic availability of specific services or pro-
cedures) simultaneously. The committee therefore considered findings in
light of the preponderance of evidence and the merits of each individual
study. Noting the importance of assessing study strengths and limita-
tions in context, Mayberry and colleagues (2000) write, “[t]he method-
ological inadequacy of an individual study may be a relatively moot point
in the context of the body of literature that gives consistent findings and
in which one study, often the more recent study, may overcome the spe-
cific failing of a previous investigation” (Mayberry, Mili, and Ofili, 2000,
p. 116).
This review yielded over 100 studies (summarized in Appendix B)
that assessed racial and ethnic variation in a range of clinical procedures,
including the use of diagnostic and therapeutic technologies. This body
of literature, however, represents only a fraction of the published studies
that investigate racial and ethnic differences in access to and use of
healthcare services. Geiger (this volume), for example, has identified over
600 such articles published over the last three decades. For a more com-
prehensive review of this literature, the reader is referred to Geiger (this
volume) or the reviews of Mayberry and colleagues (Mayberry, Mili, and
Ofili, 2000); Kressin and Petersen (2001); Sheifer, Escarce, and Schulman
(2000); Ford and Cooper (1995); and the AMA Council on Ethical and
Judicial Affairs (1990).
Cardiovascular Care
Some of the strongest and most consistent evidence for the existence
of racial and ethnic disparities in care is found in studies of cardiovascu-
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INTRODUCTION AND LITERATURE REVIEW
health factors and numbers of physician visits did not change these rela-
tionships, and they remained after controlling for age, maternal educa-
tion, insurance, poverty status, source of care, geographic location, health
status, number of bed days, number of reduced activity days, and physi-
cian visits. Similarly, Zito et al. (1998) found that white children were
twice as likely to receive psychotropic prescriptions compared with Afri-
can-American children.
A study examining parents’ perceptions of pediatric care found strik-
ing racial and ethnic differences. Weech-Maldonado et al. (2001) used
data from the National Consumer Assessment of Health Plans (CAHPS)
Benchmarking database and found that minority parents, particularly
non-English speakers, were less satisfied than white parents with pediat-
ric services, after controlling for parents’ gender, age, education, and their
children’s health status. African-American and American-Indian parents
were found to be less satisfied than whites in getting needed care, the
timeliness of care, provider communication, and health plan services.
Among Asian-American and Hispanic parents, parental satisfaction was
lower than for whites only among those who were non-English speakers.
Asian-American and Hispanic non-English speakers rated staff helpful-
ness, timeliness of care, provider communication, health plan services,
and getting needed care lower than did white parents, while Asian-Ameri-
can and Hispanic parents who were proficient in English did not differ
significantly from whites on any reports of care.
Mental Health Services
Several studies document racial and ethnic variation in receipt of men-
tal health services. Significantly, the U.S. Surgeon General recently com-
pleted a major report assessing racial and ethnic disparities in mental
health and mental healthcare that reviews much of the available litera-
ture. That report finds that more so than in other areas of health and
medicine, mental health services are “plagued by disparities in the avail-
ability of and access to its services,” and that “these disparities are viewed
readily through the lenses of racial and cultural diversity, age, and gen-
der” (U.S. DHHS, 2001a, p. vi). Major findings of the report include that:
mental illnesses are real and disabling conditions that affect all popula-
tions (regardless of race/ethnicity); striking disparities are found for ra-
cial and ethnic minorities; and these disparities impose a greater disabil-
ity burden on racial and ethnic minorities. In addition to universal
barriers to quality care (e.g., cost, fragmentation of services), the report
notes that other barriers, such as mistrust, fear, discrimination, and lan-
guage differences carry special significance for minorities in mental health
treatment, as these barriers affect patients’ thoughts, moods, and behav-
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70 UNEQUAL TREATMENT
ior. Communication and trust are particularly critical in treatment, the
report notes, and differences in the cultural perspectives of the patient
and clinician/healthcare system must be acknowledged and addressed
(U.S. DHHS, 2001a).
The U.S. Surgeon General . . . finds that more so than in other areas of
health and medicine, mental health services are “plagued by disparities in
the availability of and access to its services,” and that “these disparities are
viewed readily through the lenses of racial and cultural diversity, age, and
gender.”
Several studies have examined disparate use of psychotropic medi-
cations and mental health services and find disparities, with minorities
in some cases receiving higher quantities of medications. For example, in
a study examining prescriptions of antipsychotic medications by physi-
cians in psychiatric emergency services, Segal, Bola, and Watson (1996)
found that African-American patients received more oral doses and in-
jections of antipsychotic medications. The 24-hour dosage of antipsy-
chotic medication given to African Americans was also significantly
higher that for other patients. Analyses controlled for several clinical
factors including presence of psychotic disorder, severity of disturbance,
dangerousness, psychiatric history, if physical restraints were used,
hours spent in the emergency service, clinician’s efforts to engage patient
in treatment, and whether optimum time was spend on the evaluation.
The study also found that the tendency to overmedicate African-Ameri-
can patients was lower when a clinician’s efforts to engage the patients in
treatment were rated as being higher. Models predicting number of
medications, number of oral and injected antipsychotic and 24-hour dos-
age became non-significant.
In contrast, a study examining medication prescribed for depression
yielded different results. Melfi and colleagues (2000) assessed antidepres-
sant treatment in a population of Medicaid beneficiaries diagnosed with
depression. Analyses controlled for age, gender, Medicaid eligibility sta-
tus, and several clinical factors. Forty-four percent of whites and 27.8% of
blacks received antidepressant treatment within 30 days of the first indi-
cator of depression. White patients were more likely to receive antide-
pressants than black patients and patients in the other/unknown racial
category.
An examination of privately insured federal employees, conducted
by Padgett and colleagues (1994), assessed racial and ethnic differences in
use of inpatient psychiatric services. Analyses controlled for a variety of
predisposing factors (e.g., education, family size, racial/ethnic composi-
tion of residing county), enabling factors (region of country, salary, high
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or low option selected for insurance coverage), and need factors (annual
medical expenses, family’s annual medical expenses, other family mem-
ber receipt of inpatient psychiatric care, sum of outpatient mental heath
visits by other family members). No significant differences were found
among blacks, whites and Hispanics as to the probability of a psychiatric
hospitalization or in number of inpatient psychiatric days.
Racial and Ethnic Differences in Other Clinical and
Hospital-Based Services
Several studies document racial and ethnic disparities in other clini-
cal and hospital-based services. Ebell et al. (1995) assessed the rate of
survival by patient race following in-hospital cardiopulmonary resuscita-
tion (CPR) of 656 patients at one of three teaching hospitals. Black pa-
tients in this study were less likely than non-black patients to have an
admitting diagnosis of myocardial infarction (MI), were less likely to have
a history of coronary artery disease, but had a higher severity of illness
according to a standard screening instrument. Controlling for these vari-
ables, black patients were found to have poorer survival to discharge than
non-black patients. Because resuscitation was provided in-hospital, dif-
ferences in ambulance response time, access to telephones, or other com-
munity factors could not account for this difference. Further, because
there were no significant racial differences in the success of the resuscita-
tion effort, the difference in survival appears to be related to the quality of
care after resuscitation, or to other unmeasured factors.
Devgan et al. (2000) assessed surgical treatment for glaucoma among
large samples of African-American and white Medicare patients, and
found that African-American patients received argon laser trabeculo-
plasty or trabeculectomy surgery at nearly half of expected rates, once
the age-race prevalence of glaucoma was considered. Arozullah et al.
(1999) assessed rates of laparoscopic cholecystectomy among more than
16,000 Veterans Administration (VA) patients diagnosed with gall blad-
der or biliary disease. After controlling for patient age, marital status,
co-morbid illness, year of surgery, and hospital geographic location, the
investigators found that African-American patients who underwent
cholecystectomy were less likely than white patients to undergo the
laparoscopic procedure. In contrast, another study of VA patients (Selim
et al., 2001) found that among patients presenting with low-back pain,
“non-white” patients in higher levels of pain were more likely to receive
lumbar spine radiographs than white patients experiencing similar pain
levels, although this racial difference disappeared after controlling for
clinical characteristics.
Fewer studies have assessed the quality of basic healthcare services.
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In one such study, Ayanian et al. (1999) utilized explicit process criteria
and implicit review by physicians to assess the quality of care for patients
hospitalized with congestive heart failure and pneumonia. Using records
from a stratified random sample of over 2,000 Medicare beneficiaries, the
authors found that among patients with congestive heart failure, African
Americans received a lower overall quality of care than other patients by
implicit review, but not explicit review. Among patients with pneumo-
nia, African-American patients received a lower quality of care by explicit
criteria, but not explicit review. These differences persisted in analyses
adjusting for patient and hospital characteristics. Adjusted analyses also
revealed no significant differences in quality of care for patients from poor
communities, as compared with other patients. Similarly, in a review of
discharge data from over 1.7 million patients assessed via the Hospital
Cost and Utilization Project (HCUP-2), Harris, Andrews, and Elixhauser
(1997) found that African Americans were less likely than whites to re-
ceive major therapeutic procedures for 37 of 77 conditions, and more likely
than whites to receive a major therapeutic procedure in 9.1% of condi-
tions studied. These differences persisted even after controlling for pa-
tients’ age, expected pay source, indicators of clinical condition, and hos-
pital-level characteristics (e.g., bed size, public ownership, teaching status,
and urban location).
In a study of racial differences in mortality and resource use among
patients admitted to intensive care units, Williams et al. (1995) found no
significant differences in risk-adjusted in-hospital mortality. The authors
did find, however, that African-American patients had a shorter length of
stay and lower resource use in the first seven days compared with white
patients. For example, whites received more technological monitoring
(arterial and pulmonary artery catheters, pulse oximetry), more labora-
tory testing, and a greater proportion of life-saving treatments. These
differences persisted after adjusting for patient characteristics and insur-
ance status, leading the researchers to conclude that these differences
could reflect undertreatment for African Americans or overutilization of
services by whites.
In another study of Medicare patients, Wilson, May, and Kelly (1994)
assessed racial differences in receipt of total knee arthroplasty among
older adults with osteoarthritis. The authors found that while osteoar-
thritis was slightly, but not significantly, more common among African
Americans, whites were more likely to receive total knee arthroplasty.
This relationship held true at all income levels and could not be explained
by prior procedures or the use of alternative procedures.
White-Means (2000) assessed the use of long-term care services (paid
caregiver, therapist, mental health, dentist, foot doctor, optometrist, chi-
ropractor, ER visit, doctor visits, prescription medications) by disabled
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elderly Medicare patients, as a function of medical conditions and dis-
abilities, income, insurance status, regional and rural residence, whether
unpaid caregivers provide in-home services, and sociodemographic char-
acteristics (e.g., gender, education). Given similar medical conditions,
African-American patients were found to be less likely to use long-term
care services, particularly prescription medications and physician ser-
vices. African-American patients who lived in rural areas, small cities,
and western states or who had more joint and breathing problems were
more likely to use services. Differences in personal attributes (e.g., in-
come, health) did not fully explain racial differences in use of prescrip-
tions and physician services. Similarly, Khandker and Simoni-Wastila
(1998) assessed racial differences in use and level of use of prescription
drugs among a sample of Medicaid patients, controlling for age, sex, and
Medicaid eligibility characteristics. African-American children were
found to use 2.7 fewer prescriptions compared with white children. Afri-
can-American adults used 4.9 fewer prescriptions, and African-American
elders used 6.3 fewer prescriptions than white elders. White Medicaid
enrollees had higher use and spending than black enrollees across most
high-volume therapeutic drug categories.
In a study of primary care, Shi (1999) assessed patients’ perceptions of
intake, service delivery, referral, and follow-up among nearly 15,000
white, African-American, Hispanic, and Asian respondents to the Medi-
cal Expenditure Panel Survey (MEPS). Controlling for patients’ perceived
need for care, ability to obtain services, and frequency of use of care, Shi
found that African-American, Hispanic, and Asian-American patients
tended to experience greater barriers to receiving primary care. Hispanic
patients were over 40% less likely to have a usual source of care, while
those African-American and Hispanic patients who did report a regular
primary care provider tended to reference a facility (hospital or clinic)
rather than an individual provider. African Americans were less likely to
have a primary care specialist as a regular provider. All three minority
groups were 39% to 48% more likely than whites to report long waiting
periods before seeing their care provider, but Asian-American patients
were more likely than any racial/ethnic groups to report that getting an
appointment was “very difficult.” On an encouraging note, this study
also found that overwhelming numbers of whites and minority patients
reported confidence in their provider and that their usual care provider
“listened to them”—over 90% agreement for all groups.
A small number of studies have assessed racial and ethnic differences
in preventable hospitalizations. Preventable hospitalizations are those
that might not have occurred had patients received timely and appropri-
ate preventive care in the case of acute conditions, as well as effective and
continuous care for chronic conditions. Gaskin and Hoffman (2000) as-
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sessed rates of preventable hospitalizations among children, working-age
adults, and the elderly, while adjusting for a range of sociodemographic
(e.g., age, income, insurance status), community-level (e.g., neighborhood
characteristics, physicians, and hospital beds per capita), and health status
(e.g., co-morbidities) variables. Results indicated that African Americans
and Hispanics were significantly more likely to be hospitalized for pre-
ventable conditions than whites, even after adjusting for patient differ-
ences in healthcare needs, socioeconomic status, insurance coverage, and
the availability of primary care providers. Subsequent analyses of indi-
viduals within similar health insurance plans confirmed that these differ-
ences exist independently of insurance status. The findings were limited
by the lack of information on the competency of providers seen by minor-
ity patients, the adequacy of insurance plans, and personal health-seeking
behavior.
Minority patients are more likely to undergo amputation than white
patients. Such is the case with limb amputation, where more than 50,000
procedures are performed each year among patients with diabetes.
Guadagnoli et al. (1995) assessed racial differences in the use of amputa-
tion and leg-sparing surgery among a random sample of Medicare pa-
tients. The authors found that African-American patients were nearly
twice as likely as whites to undergo above-knee amputation, and were
slightly more likely than whites to undergo toe and/or foot amputation,
controlling for co-morbid disease, prior hospitalizations, geographic re-
gion, hospital teaching status, and other factors. Whites, on the other
hand, were more likely to undergo lower-extremity arterial revasculari-
zation and percutaneous transluminal angioplasty than African-Ameri-
can patients. The study did not, however, control for disease severity,
although the authors note that controls for co-morbid disease and prior
hospitalizations may attenuate this potential confounding factor. Simi-
larly, Gornick et al. (1996), in a study of 26.3 million Medicare beneficia-
ries, found that African Americans were more likely than whites to un-
dergo bilateral orchiectomy or amputation of the lower limbs, even after
controlling for income differences. Finally, Collins et al. (2002) assessed
racial and ethnic differences in rates of lower extremity amputation ver-
sus lower extremity bypass revascularization among a sample of VA pa-
tients with peripheral arterial disease. In this prospective study, the au-
thors statistically adjusted for a range of factors that may be associated
with the use of amputation versus revascularization (e.g., presence of dia-
betes, hypertension, heart disease, or other co-morbid conditions, behav-
ioral risk factors such as smoking or alcohol use, geographic location of
the VA hospital), and found that African-American and Hispanic patients
were 1.5 and 1.4 times, respectively, more likely than white patients to
undergo amputation than revascularization (Collins et al., 2002).
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Gaps in Existing Research
While the research reviewed here points to significant variation in
access to and use of services by race and ethnicity, several gaps exist that
must be addressed to develop a more comprehensive understanding of
racial and ethnic disparities in healthcare. The most significant gap in this
research is the failure to identify mechanisms by which these disparities
occur. A robust research agenda is needed to better understand how the
process and structure of care may vary by patient race (see chapter on
“Needed Research”). Such research must consider the range of influences
on patients’ and providers’ attitudes and expectations in the clinical en-
counter, clinical decision-making processes employed by healthcare pro-
viders and the influence of patient race in these processes, the nature and
quality of communication between patients and providers (particularly
as it occurs across cultural and/or linguistic lines), the environments and
settings in which care is delivered, and other factors that will be discussed
later in this report. In addition, as noted below, no research has yet illu-
minated the relative contribution of these factors to the healthcare dis-
parities observed in the literature.
Assessing sources of disparities in care in the current literature is also
complicated by many methodological considerations. Attempts to con-
trol for SES differences are inconsistent, with some researchers employing
patient income or education as sole indicators of SES, and others using
proxy variables such as estimates of income on the basis of patients’ zip
code information. Most studies control for insurance status, but some
combine data from patients insured via different types of health systems
(e.g., HMO or fee-for-service) or different sources of insurance coverage
(e.g., public vs. private).
Some studies have explicitly examined differences in where racial and
ethnic groups receive care (e.g., public vs. private healthcare settings),
and clinical factors such as stage of illness progression at presentation
(e.g., on average, ethnic minority cancer patients present at later stages of
disease progression, thereby limiting treatment options) or other co-mor-
bid factors that may limit treatment options. Other studies have at-
tempted to control for the quality of diagnostic evaluation and disease
severity. Adequate assessment of these factors, however, is often limited
by a lack of sufficient information in administrative claims data upon
which many studies are based. These datasets often rely on crude or in-
complete measures of disease severity and the types of treatment pro-
vided, and contain limited information on prior diagnoses or treatments.
Further, most studies (with the exception of several studies of cardiovas-
cular care) lack comparison to standards for the appropriateness of care,
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leaving open the question of whether care received was sufficient given
the type and severity of disease.
Finally, one of the most significant limitations of existing research is
the failure to analyze differences in care beyond comparisons of African-
American and white patients. With the exception of a few large studies
conducted in ethnically diverse regions of the United States such as Cali-
fornia and New York, few studies have assessed whether disparities in
care exist for Hispanic and Asian-American populations. Further, few
studies have examined subgroup differences within these populations.
These issues are particularly salient for Hispanic and Asian-American
subgroups, whose healthcare may be complicated by linguistic and cul-
tural differences, immigration status, and other access-related issues.
The Extent of Racial and Ethnic Disparities in Healthcare
As the discussion above suggests, many factors influence the provi-
sion and receipt of diagnostic and therapeutic healthcare services. Fur-
ther, healthcare outcomes are influenced by a wide variety of factors,
many of which are beyond the scope of clinical factors such as the efficacy
of treatment protocols. Assessing the relative contribution of the many
patient, provider, and system-level influences on care is therefore an im-
precise exercise. Similarly, assessing the extent of racial and ethnic differ-
ences in healthcare that are not otherwise attributable to known factors
such as access to care is not likely to yield reliable estimates.
Some studies have attempted to assess the extent of racial and ethnic
disparities in a small number of key indicators of healthcare use. Weinick,
Zuvekas, and Cohen (2000) assessed racial and ethnic differences in ac-
cess to and use of healthcare services (i.e., having a usual source of care
and the use of ambulatory care services), and evaluated the magnitude of
these differences above and beyond access-related factors such as insur-
ance status, income, and other socioeconomic characteristics. The authors
found that after adjusting for health insurance, income, age, sex, marital
status, education, health status, region of the country, and residence in a
metropolitan area, Hispanics and African Americans were significantly
more likely to lack a usual source of care and were less likely to use any
ambulatory care services than white Americans. Hispanics were nearly
10% more likely to lack a usual source of care, and African Americans and
Hispanics were nearly 9% and over 10% less likely, respectively, to have
made any ambulatory care visits. The authors performed additional
analyses to assess the extent of these disparities, simulating conditions in
which all racial and ethnic groups earned equivalent income and were
insured at the same level. For all groups, 55% to 77% of the observed
differences remained, demonstrating that “health insurance coverage and
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income typically each account for only about one fifth, and never even as
much as one half, of the disparities . . . observed” (Weinick, Zuvekas, and
Cohen, 2000, p.43). The authors acknowledge, however, that these racial
and ethnic disparities in the use of services could be related to unmea-
sured factors, such as job-related and non-financial barriers, poor cultural
and linguistic access, an inadequate geographic distribution of healthcare
providers in racial and ethnic minority communities, and other factors.
More such studies are needed to assess the relative contribution of
access-related factors (e.g., insurance status), other socioeconomic and
geographic variables (e.g., patients’ education, income, and the availabil-
ity of healthcare providers in a community), and racial and ethnic differ-
ences in healthcare preferences and attitudes to determine the extent of
disparities in care. This research is needed across a range of health condi-
tions. Currently, however, this research does not present a sufficient em-
pirical foundation to assess the extent of racial and ethnic healthcare dis-
parities. The committee therefore concludes that while evidence of racial
and ethnic disparities in care appears consistently across a range of health
conditions and medical procedures, attempts to assess or quantify the ex-
tent of these disparities, based on evidence currently available, are not
likely to prove to be reliable or valid.
SUMMARY
Racial and ethnic minority patients are found to receive a lower qual-
ity and intensity of healthcare and diagnostic services across a wide range
of procedures and disease areas. This finding is remarkably consistent
and robust, as only a handful of the several hundred studies reviewed
here and by others (e.g., Geiger, this volume; Kressin and Peterson, 2001;
Mayberry et al., 2000) find no racial and ethnic differences in care. In
studies where patients’ sociodemographic characteristics (e.g., education
level, income), insurance status (e.g., public or privately funded insur-
ance) and clinical factors (e.g., co-morbid illness, severity of disease) are
controlled, these racial and ethnic differences are generally attenuated,
but rarely disappear completely. Further, in a few well-designed, pro-
spective studies, these disparities in care have been linked to poorer clini-
cal outcomes and higher mortality among minorities (Peterson et al., 1997;
Bach et al., 1999).
Insurance status, in particular, emerges in several studies as a key
predictor of the quality of care that patients receive. The privately in-
sured generally receive a higher quality of care than those who are in-
sured through publicly funded sources (e.g., Medicaid), or those who have
no health insurance. Racial and ethnic minorities are disproportionately
represented between the latter two categories, yet when sources of insur-
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ance are controlled statistically or by study design, race and ethnicity re-
main as significant predictors of the quality of care. This disparity is best
illustrated in studies of care among Medicare populations (Gornick et al.,
1996), which reveal lower rates of use of effective, higher technology diag-
nostic and therapeutic procedures among minorities for illnesses such as
heart disease, cancer, and other chronic illnesses, and higher rates of less
desirable procedures, such as amputation and bilateral orchiectomy.
The quality of care that minority and non-minority patients receive is
also partly a function of where these populations tend to receive care.
Several studies note that patient care is of lower quality in non-teaching
hospitals, public hospitals and clinics than in teaching hospitals or private
settings. While some minorities are more likely to receive care in the
former settings, they are more likely to access care in emergency depart-
ments, and are less likely to have a regular source of care (Collins, Hall,
and Neuhaus, 1999). Further, minorities tend to have lower access than
whites to specialty care, and are less likely to be treated in settings that
offer higher-technology procedures—all factors related to the quality of
care in the studies reviewed here. Again, however, when these variables
are controlled statistically or by study design, racial and ethnic minorities
tend to receive a lower quality of care.
Most studies have compared the quality of care received by minority
patients relative to that of whites as the standard of comparison. This
type of analysis, however, fails to provide a complete picture of the ap-
propriateness of care, as whites may over-utilize some services, and racial
differences in the severity of disease at presentation or treatment response
may contraindicate the use of similar therapeutic interventions. Some of
the best-designed studies reviewed here, however, assessed the quality of
care provided relative to well-established clinical criteria, and use objec-
tive diagnostic measures to assess the extent and severity of disease. In
these studies, race and ethnicity again typically emerge as significant pre-
dictors of the quality of care received, indicating that disparities in care
are not simply a function of disproportionate use by whites or greater
disease severity among minorities.
These findings appear consistently in studies of differences in care
received by African-American and white populations, and increasingly,
in studies involving Hispanic patients. A few studies suggest that Asian
Americans also are less likely to receive the same quality of care as whites
(e.g., Carlisle et al., 1995). This review produced no studies where the
quality of care for American Indian, Alaska Native, or Pacific Islander
populations were explicitly studied, or where the sample size of these
populations permitted analysis. Further, in few instances were subgroups
of these populations explicitly studied. As will be discussed in a later
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chapter, research is urgently needed to assess the quality of care for these
populations relative to the burden of illness.
A few of the studies that find no racial and ethnic differences in care
indicate that characteristics of health systems may serve an important role
in mediating these disparities. Studies of patients in military healthcare
systems reviewed here indicate a lower prevalence of racial or ethnic dif-
ferences in the quality of healthcare that active-duty personnel or their
families receive. Similarly, some studies of patients in VA systems dem-
onstrate reductions in racial and ethnic differences in care, although these
studies are less consistent. Future research must assess the range of fac-
tors that distinguish these heath systems from other private or publicly
funded systems to better understand how patient race and ethnicity are
related to care and care outcomes. For example, the impact of differences
in provider profiles should be investigated, as VA hospitals commonly
are staffed by a larger percentage of trainees than other systems. None-
theless, these studies suggest that characteristics of these health systems,
perhaps related to universal or equal access to care, may attenuate dis-
parities that are typically found in other systems.
Collectively, these findings support the hypothesis that patients’ race
and ethnicity significantly predict the quality and intensity of care that
they receive. Succeeding chapters of this report will review the historical
context in which these disparities occur, and examine the types of settings
in which minorities typically receive care, as well as the characteristics of
healthcare providers that serve them. Potential sources of healthcare dis-
parities will be closely examined, including patient preferences; provider
biases, stereotyping, and clinical decision-making; and the impact of fi-
nancial and institutional characteristics of health systems on the quality of
care for minority patients. Finally, several strategies to eliminate these
disparities are proposed, and future research directions are outlined.
Finding 1-1: Racial and ethnic disparities in healthcare exist and,
because they are associated with worse outcomes in many cases, are
unacceptable.
Racial and ethnic disparities in healthcare exist. These disparities
are consistent and extensive across a range of medical conditions
and healthcare services, are associated with worse health outcomes,
and occur independently of insurance status, income, and educa-
tion, among other factors that influence access to healthcare. These
disparities are unacceptable.
Representative terms from entire chapter:
racial differences
