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Risa Lavizzo-Mourey
Looking Into the Melting Pot
Nearly one in every ten U.S. residents were born
elsewhere, the highest percentage of foreign born
residents since the 1930’s.
Look Ahead to an America of All
‘Minorities’ in a Few Years
With changing immigration, no group will be a majority.
California Population by Race
30%
5%
18%
1%
Latino
White
Black
Asian
Am Indian
Disparities in Health Care
• African Americans are 50% less likely to get
heart bypass surgery
• African Americans are 25% less likely to get
pain medication
• African Americans are 54% as likely to get
colon cancer screening procedures
• African Americans with lymphoma are 34-45%
as likely to undergo a bone marrow transplant
• African Americans are 12.7% less likely to get
surgery for lung cancer
The Effect of Race and Sex on Physicians'
Recommendations for Cardiac Catheterization
• 720 physicians viewed
recorded interviews
• Reviewed data about
a hypothetical patient
• The physicians then made
recommendations about
that patient's care
Source: Schulman et.al. NEJM 1999;340:618.
The Effect of Race and Sex on Physicians'
Recommendations for Cardiac Catheterization
•
Women (OR =0.60) and blacks (OR =0.60) were less
likely to be referred for cardiac catheterization than
men and whites, respectively.
• Black women were significantly less likely to be
referred for catheterization than white men (OR= 0.4)
Source: Schulman et. al., NEJM 1999;340:618.
Committee on Understanding and Eliminating
Racial and Ethnic Disparities in Health Care
IOM COMMITTEE
ALAN R. NELSON, M.D.
HEALTH SCIENCES POLICY
BOARD LIASON
MARTHA N. HILL, Ph.D., R.N.
GLORIA E. SARTO, M.D., Ph.D.
RISA LAVIZZO-MOUREY, M.D., M.B.A.
JOSEPH R. BETANCOURT, M.D., M.P.H.
IOM PROJECT STAFF
M. GREGG BLOCHE, J.D., M.D.
BRIAN D. SMEDLEY
W. MICHAEL BYRD, M.D., M.P.H.
ADRIENNE Y. SITH
JOHN F. DOVIDIO, Ph.D.
DANIEL J. WOOTEN
JOSE ESCARCE, M.D., Ph.D.
THELMA L. COX
SANDRA ADAMSON FRYHOFER, M.D.
SYLVIA I. SALAZAR
THOMAS INUI, Sc.M., M.D.
JENNIE R. JOE, PH.D., M.P.H.
IOM STAFF
THOMAS McGUIRE, Ph.D.
ANDREW M. POPE
CAROLINE REYES, M.D.
ALDEN CHANG
DONALD STEINWACHS, Ph.D.
CARLOS GABRIEL
DAVID R. WILLIAMS, Ph.D., M.P.H.
PAIGE BALDWIN
Committee on Understanding
and Eliminating Racial and Ethnic
Disparities in Health Care
Study Charge:
• 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 healthcare, 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.
Committee on Understanding
and Eliminating Racial and Ethnic
Disparities in Health Care
Methods:
• Literature review
• Public workshops
• Focus groups
Committee on Understanding
and Eliminating Racial and Ethnic
Disparities in Health Care
Literature Review:
• Literature searches via PUBMED or MEDLINE
– Keywords:
• Race, racial, ethnicity, minority/ies, groups, African American,
Black, American Indian, Alaska Native, Native American,
Asian, Pacific Islander, Hispanic Latino
• Differences, disparities, care
• Cardiac, coronary, cancer, asthma, HIV, AIDS, pediatric,
children, mental health, psychiatric, eye, ophthalmic,
glaucoma, emergency, diabetes, renal, gall bladder, ICU,
peripheral vascular, transplant, organ, cesarean, prenatal, hip,
hypertension, injury, surgery/surgical, knee, pain, procedure,
treatment, diagnostic
Committee on Understanding
and Eliminating Racial and Ethnic
Disparities in Health Care
Literature Review:
• Only studies
– control or adjustment for racial and ethnic
differences in insurance status
• Other “threshold” criteria included:
– primary purpose was to examine variation in
medical care by race and ethnicity
Committee on Understanding
and Eliminating Racial and Ethnic
Disparities in Health Care
Literature Review:
• The committee ranked studies on several criteria:
–
–
–
–
–
–
Control of insurance status
Patient socioeconomic status
Clinical data
Prospective or retrospective data collection
Appropriate control for patient co-morbid conditions
Control for racial differences in disease severity or stage
of illness at presentation
– Patients’ appropriateness for procedures
– Rates of refusal or patient preferences
Differences, Disparities, and
Discrimination: Populations with Equal
Access to Health Care
Difference
Minority
Non-Minority
Clinical Appropriateness
and Need
Patient Preferences
The Operation of Healthcare
Systems and the Legal and
Regulatory Climate
Discrimination:
Biases and Prejudice, Stereotyping,
and Uncertainty
Populations with Equal Access to Health Care
Disparity
Summary Of Findings
• Racial and ethnic disparities in health care
exist and, because they are associated with
worse outcomes in many cases, are
unacceptable.
• Racial and ethnic disparities in health care occur in the
context of broader historic and contemporary social
and economic inequality, and evidence of persistent
racial and ethnic discrimination in many sectors of
American life.
• Many sources – including health systems, health care
providers, patients, and utilization managers –
contribute to racial and ethnic disparities in health
care.
Racial and Ethnic Disparities in Health Care Exist
and Are Associated With Worse Outcomes
Cardiovascular care:
• The preponderance of studies find that even after
adjustment for many potentially confounding factors--including racial differences in access to care, disease
severity, site of care (e.g. geographic variation or type
of hospital or clinic), disease prevalence, comorbidity or
clinical characteristics, refusal rates, and overuse of
racial and ethnic
disparities in cardiovascular care remain.
services by whites -
Summary of Most Rigorous Studies of Racial
and Ethic Differences in Cardiovascular Care
Author
Year
Type of
Data
Insurance
Prospective/
Retrospective
Adjust for
Comorbidity
Disease
Severity
Appropriateness
Outcomes
Find
Disparities
?
Conigliaro
et. al.
2000
Clinical
VA health
care
system
Retrospective
Yes
Yes
Yes
No
Yes
Carlisle
et. al.
1999
Clinical
records
and ED
logs
ESRD
Medicare
Retrospective
No
No
Yes
No
No
Daumit
et. al.
1999
Clinical
ESRD
Medicare
Prospective
Yes
Yes
Yes
Yes
Yes
Leape
et. al.
1999
Clinical
and lab
data from
medical
records
Statistical
adjustment
for type of
insurance
Retrospective
No
Yes
Yes
No
No
Author
Year
Type of
Data
Insurance
Prospective/
Retrospective
Adjust for
Comorbidity
Disease
Severity
Appropriateness
Outcomes
Find
Disparities?
Scirica
et. al.
1999
Clinical
Statistical
adjustment
for type of
insurance
Prospective
Yes
No
Yes
No
Yes
Laouri
et. al.
1997
Clinical
and lab
data
from
medical
use
records
Not assessed,
but patients
sampled
from both
public and
private
hospitals
Retrospective,
with patient
follow-up
Yes
Yes
Yes
No
Yes
Maynard
et. al.
1997
Clinical
data
Statistical
adjustment
for payment
by Medicaid
Prospective
Yes
Yes
No
Yes
No
1997
Clinical
data
Statistical
adjustment
for type of
insurance
Prospective
Yes
Yes
Peterson
et. al.
Yes
Yes
Yes
Racial and Ethnic Disparities in Health Care Exist
and Are Associated With Worse Outcomes
Cancer Treatment:
• Less clear and consistent than studies of
cardiac care
•
• Several studies demonstrate significant racial
differences in the receipt of appropriate cancer
treatments and analgesics
Racial Differences in the Treatment of
Early-Stage Lung Cancer
Source: Bach, Peter B. Et al. NEJM 1999;341:1198-205
Racial Differences in the Treatment of
Early-Stage Lung Cancer
Source: Bach, Peter B. Et al. NEJM 1999;341:1198-205
Racial and Ethnic Disparities in Health Care Exist
and Are Associated With Worse Outcomes
Renal Transplantation:
• African-American patients (and in some instances,
other ethnic minority patients) are
– less likely to be judged as appropriate for
transplantation
– less likely to appear on transplantation waiting lists
– less likely to undergo transplantation procedures,
even after patients’ insurance status and other
factors are considered.
The Effect of Patients' Preferences on
Racial Differences in Access to Renal
Transplantation
Percentage of Patients
Black women
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
White women
80.3%
Black men
White men
82.2%
68.9%
59.6%
67.9%
57.9%
40.3%
Referred
for Evaluation
40.6%
Placed on Waiting List
or Received Transplant
Source: Epstein et. al. NEJM 1999.
Racial and Ethnic Disparities in Health Care Exist
and Are Associated With Worse Outcomes
HIV/AIDS Treatment:
• African Americans are
– less likely to receive antiretroviral therapy
– less likely to receive prophylaxis for pneumocystis
pneumonia
– less likely to receive protease inhibitors than nonminorities with HIV
• These disparities remain even after adjusting for age,
gender, education, and insurance coverage.
Racial and Ethnic Disparities in Health Care Exist
and Are Associated With Worse Outcomes
Asthma Treatment:
• African Americans are
– more likely to recieve care in ER and to be hospitalized
– less likely to be seen by an asthma specialist
– more likely to use corticosteroids
– less likely to be prescribed anticholinergic medications.
• Despite high levels of access, African Americans had lower
disease-related quality of life scores
• Findings of disparities in asthma care are mixed, and may vary
as a function of the education level of patient populations
studied
1.Ayanian, J,Z., “Race, Class, and the Quality of Medical Care” JAMA 1994; 271(15): 1207-1208
2.Ayanian, J.Z. et al, “Racial Differences in the Use of Revascularization Procedures After Coronary Angiography”
JAMA 1993; 269(20): 2642-2646
3.Escarce, J.J. et al, Racial differences in the Elderly’s Use of Medical Procedures and Diagnostic Tests” American
Journal of Public Health. 1993; 83(7): 948-954.
4.Franks, A.L. et al, “Racial differences in the use of invasive coronary procedures after acute myocardial
infarction in Medicare beneficiaries” Ethnicity and Disease 1993; 3(3): 213-220
5.Gibaldi, M., “Ethnic differences in the assessment and treatment of disease” Pharmacotherapy.
176.
1993; 13(3): 170-
6.Giles, w.H. et al “Race and Sex Differences in Rates of Invasive Cardiac Procedures in U.S. Hospitals” Archives of
Internal Medicine. 1995; 155: 318-324
7.Goldberg K.C. et al, “Racial and Community Factors Influencing Coronary Artery Bypass Graft Surgery Rates for all
1986 Medicare Patients” JAMA. 1992; 267(11): 1473-1477.
8.Hannan, EL and H Kilburn, JF O’Donnell, G Lukacik, EP Shields. “Interracial Access to Selected Cardiac Procedures
for Patients Hospitalized with Coronary Artery Disease in New York State” Medical Care. 1991; 29(5): 430-441
9.Johnson, P.A. et al, “Effect of race on the Presentation and Management of Patients with Acute Chest Pain”
of Internal Medicine. 1993; 118(8): 593-601.
Annals
10.Kahn, K.L. et al, “Health care for Black and Poor Hospitalized Medicare Patients” JAMA 1994; 271(15): 1169-1174
11.Maynard, C. et al, “Blacks in the Coronary Artery Surgery Study (CASS):Race and Clinical Decision Making”
American Journal of Public Health 1986; 76(12): 1446-1448.
12.McBean AM, Warren JL, Babish JD. “Continuing Differences in the rates of percutaneous transluminal coronary
angioplasty and coronary artery bypass graft surgery between elderly black and white Medicare beneficiaries”
American Heart Journal 1994; 127(2): 287-295
13.Oberman, A. and Cutter, G., “Issues in the natural history and treatment of coronary heart disease in black
populations: Surgical treatment
14.Soucie, J. M. et al, “Race and sex differences in the identification of candidates for rental transplantation”
American Journal of Kidney Diseases 1992; 19(5): 414-419
15.Wenneker M.B. and Epstein, A.M. “Racial Inequalities in the Use of Procedures for Patients With Ischemic Heart
Disease in Massachusetts” JAMA. 1989; 261(2): 253-257
16.Wilson, MG, DS May, JJ Kelly. “Racial Differences in the Use of Total Knee Arthroplasty for Osteoarthritis
Among Older Americans” Ethnicity & Disease. 1994; 4: 57-67
17.Yergen, J. etal “Relationship Between Patient Race and the Intensity of Hospital Services” Medical Care.
25(7): 592-603
1987;
18.BachP. et al Racial Differences in the Treatment of Early Stage Lung Cancer NEJM 1999;341:1198-205
19. Care needs of terminally ill nursing home residents, JAGS 46:1091-1096, 1998
20. The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization Schulman et al N. E J. M
1999;340:618
21.
24.
25.
26.
Summary Of Findings
• Racial and ethnic disparities in health care exist and,
because they are associated with worse outcomes in
many cases, are unacceptable.
• Racial and ethnic disparities in health care
occur in the context of broader historic and
contemporary social and economic inequality,
and evidence of persistent racial and ethnic
discrimination in many sectors of American
life.
• Many sources – including health systems, health care
providers, patients, and utilization managers –
contribute to racial and ethnic disparities in health
care.
Byrd WM, Clayton LA. 2000.
An American Health Dilemma. Volume 1.
A Medical History of African Americans and
the Problem of Race: Beginnings to 1900.
New York, Routledge.
“I have often contemplated whether, as a physician, I can
rise above the attitudes of the society in which I was born
and live and the city in which I practice. Can I learn to see
through the faces of the people I treat and deliver to every
one of them the highest quality care I have been trained to
provide? Can I assist my patients in negotiating the racial
prejudice that lines the road between my office and the
rest of the health care system?” -Neil Calman, MD
Summary Of Findings
• Racial and ethnic disparities in health care exist and,
because they are associated with worse outcomes in
many cases, are unacceptable.
• Racial and ethnic disparities in health care occur in the
context of broader historic and contemporary social
and economic inequality, and evidence of persistent
racial and ethnic discrimination in many sectors of
American life.
• Many sources – including health systems,
health care providers, patients, and utilization
managers – contribute to racial and ethnic
disparities in health care.
What Are Potential Sources of
Disparities in Care?
• Health systems-level factors: financing,
structure of care; cultural and linguistic
barriers
• Patient-level factors: patient preferences
and behaviors
• Disparities arising from the clinical
encounter
Western Bioethics on the Navajo
Reservation - Benefit or Harm?
JA Carres and
LA Rhodes
JAMA 1995; 274: 826-829
Hispanics and African Americans More
Likely to Feel Treated with Disrespect
Percent of adults who felt they were treated with disrespect*:
20%
16%
18%
13%
11%
10%
9%
0%
Total
White
African Hispanic
Asian
American
American
*Felt disrespected because of ability to pay, to speak English, or of their race/ethnicity.
Source: The Commonwealth Fund 2001 Health Care Quality Survey
One in Five Have Gone Without Care
When Needed Due to Language Obstacles
Spanish Speaking Latino Data
19% Have not sought care when
needed due to language barrier
HQ11:
In the course of the past year, how many times were you sick, but
decided not to visit a doctor because the doctor didn’t speak Spanish
or have an interpreter?
Minorities Face Greater Difficulty in
Communicating With Physicians
Percent of adults with one or more communication problems*
40%
33%
27%
23%
20%
19%
16%
0%
Total
White
African Hispanic Asian
American
American
Base: Adults with health care visit in past two years
*Problems include understanding doctor, feeling doctor listened, had questions but did not ask.
Source: The Commonwealth Fund 2001 Health Care Quality Survey
Minorities More Likely to Forgo
Asking Questions of Their Doctor
Percent of adults reporting they had questions which
they did not ask on last visit:
25%
19%
20%
15%
12%
13%
14%
10%
10%
5%
0%
Total
White
African Hispanic
Asian
American
American
Base: Adults with health care visit in past two years
Source: The Commonwealth Fund 2001 Health Care Quality Survey
Minorities Less Likely to
Receive Care at Doctor’s Office
Percent of adults reporting doctor’s office as regular source of care:
100%
76%
80%
66%
73%
59%
50%
0%
Total
White
African Hispanic Asian
American
American
Source: The Commonwealth Fund 2001 Health Care Quality Survey
Minority Are Less Confident They Will
Receive Good-Quality Health Care
in the Future
Percent of adults very confident they can get good-quality care in future:
60%
49%
52%
47%
40%
40%
39%
20%
0%
Total
White
African Hispanic
Asian
American
American
Source: The Commonwealth Fund 2001 Health Care Quality Survey
Summary Of Findings
• Bias, stereotyping, prejudice, and clinical
uncertainty on the part of healthcare providers
may contribute to racial and ethnic disparities
in healthcare.
• Racial and ethnic minority patients are more likely
than white patients to refuse treatment, but differences
in refusal rates are generally small, and minority
patient refusal does not fully explain healthcare
disparities.
Disparities in the Clinical Encounter:
The Core Paradox
• Bias
No evidence suggests that providers are more likely
than the general public to express biases, but some
evidence suggests that unconscious biases may exist
• Uncertainty
A plausible hypothesis, particularly when providers
treat patients that are dissimilar in cultural or
linguistic background
• Stereotyping
Evidence suggests that physicians, like everyone else,
use these ‘cognitive shortcuts’
Disparities in the Clinical Encounter:
The Core Paradox
How could well-meaning and highly educated
health professionals, working in their usual
circumstances with diverse populations of
patients, create a pattern of care that appears to
be discriminatory?
Stereotyping: A Definition
Stereotyping - the process by which people
use social categories (e.g. race, sex) in
acquiring, processing, and recalling
information about others.
Patient
Race/Ethnicity
Physician
Beliefs
About Patient
(Beliefs about
social and
behavioral
factors and
Resources.
Includes
conscious and
unconscious
activated beliefs)
Patient Behavior in
Encounter
(eg. Question-asking
Self-disclosure,
assertiveness)
Physician
Interpretation
of Symptoms
Physician
Clinical
Decision-Making
(Diagnosis, Treatment
Recommendation)
Treatment
Received
Provider Interpersonal
Behavior
(eg. Participatory style,
warmth, content, information
giving, question-asking)
Patient
Satisfaction
Patient Cognitive & Affective States
(eg. Acceptance of medical advice, attitude, self-efficacy, intention)
Patient Behaviors
(eg. Adherence,
self-management,
utilization)
Stereotyping: When Is It in Action?
Situations characterized by:
• time pressure
• resource constraints
• high cognitive demand
Promote stereotyping due to the need for cognitive
‘shortcuts’ and lack of full information.
Summary Of Findings
• Bias, stereotyping, prejudice, and clinical uncertainty
on the part of healthcare providers may contribute to
racial and ethnic disparities in healthcare.
• Racial and ethnic minority patients are more likely
than white patients to refuse treatment, but differences
in refusal rates are generally small, and minority
patient refusal does not fully explain healthcare
disparities.
The Effect of Patients' Preferences on
Racial Differences in Access to Renal
Transplantation
Epstein et al NEJM 1999;
341:
1661-1669
Recommendations:
Actions Must be Sustained and
Comprehensive
• Increase awareness of racial and ethnic
disparities in health care among the general
public and key stakeholders, and increase
health care providers’ awareness of disparities.
Recommendations:
Legal, Regulatory, And Policy
• Avoid fragmentation of health plans along
socioeconomic lines
•
Strengthen the stability of patient-provider
relationships in publicly funded health plans
• Increase U.S. racial and ethnic minorities among health
professionals
• Apply the same managed care protections to publicly
funded HMO enrollees that apply to private HMO
enrollees
• Provide greater resources to the U.S. DHHS Office of
Civil Rights to enforce civil rights laws
Recommendations: Health Care System
• Promote the consistency and equity of care through the
use of evidence-based guidelines;
• Structure payment systems to ensure an adequate
supply of services to minority patients, and limit
provider incentives that may promote disparities;
• Provide incentives for practices that barriers and
encourage evidence-based practice;
• Promote the use of interpretation services where
community need exists.
Recommendations: Education
• Patient education programs
– To increase patients’ knowledge of how to best
access care
– To participate in treatment decisions.
• Integrate cross-cultural education into the
training of all current and future health
professionals.
Recommendations:
Data Collection And Monitoring
• Collect and report data on health care access and
utilization by patients’
–
–
–
–
race
ethnicity
socioeconomic status
where possible, primary language
• Include measures of racial and ethnic disparities in
performance measurement;
• Monitor progress toward the elimination of health care
disparities;
Recommendations: Research
• Conduct further research to
– identify sources of racial and ethnic
disparities
– assess promising intervention strategies
• Conduct research on barriers to eliminating
disparities.
Actions Must
be Sustained and
Comprehensive