Racial disparities in receipt of health care services have been documented consistently in the United States. One issue is whether lower receipt of some procedures by ethnic minorities is due to their having less adequate insurance than whites. Another issue is whether this lower health care use is a sign of lower quality of care for minorities, that is, are minorities not receiving clinically appropriate procedures or is there overuse of procedures or inappropriate care among whites. A third issue is the extent to which minority attitudes and preferences for care affect racial disparities in receipt of health care services.
Three studies supported by the Agency for Healthcare Research and Quality address these issues and are described here. The first study (HS09473) shows that elderly blacks insured by Medicare are far less likely than Medicare-insured elderly whites to receive a flu shot, regardless of whether they are insured by a managed care or fee-for-service (FFS) plan. The second study (HS07098) reveals that coronary angioplasty is overused (clinically inappropriate) more often by white men than any other group. A third commentary (HS09775) suggests that asking patients about their preferences for care alternatives may reinforce the racial disparities in care that health care policymakers have pledged to remedy.
Schneider, E.C., Cleary, P.D., Zaslavsky, A.M., and Epstein, A.M. (2001, September). "Racial disparity in influenza vaccination: Does managed care narrow the gap between African Americans and whites?" Journal of the American Medical Association 286(12), pp. 1455-1460.
Elderly blacks insured by Medicare are far less likely than Medicare-insured elderly whites to receive flu shots, regardless of whether they are insured by managed care or FFS plans, according to this study. Researchers analyzed responses of 13,674 Medicare-insured, elderly people to the 1996 Medicare Current Beneficiary Survey. They found that 68 percent of whites versus 46 percent of blacks received flu shots. In general, those in Medicare managed care programs were more likely than those in FFS plans to receive flu shots (71 vs. 65 percent). However, the racial disparities in vaccination rates between whites and blacks were nearly the same, regardless of whether individuals were in FFS or managed care plans.
Racial disparities did not change when the researchers controlled for other factors, including patientsŐ attitudes toward medical care, their sex, education, or other illnesses. The most common reasons offered for not receiving a flu shot were stated by the same proportion of blacks and whites and those in either managed care or FFS programs. Reasons cited were: they did not know the flu shot was needed (21 percent), thought the shot could cause flu (18 percent), thought it could have adverse effects (15 percent), did not think it would prevent flu (15 percent), and did not think about it or missed it (13 percent).
Schneider, E.C., Leape, L.L., Weissman, J.L., and others. (2001, September). "Racial differences in cardiac revascularization rates: Does 'overuse' explain higher rates among white patients?" Annals of Internal Medicine 135, pp. 328-337.
Individuals suffering shortness of breath, chest pains, or other symptoms of coronary artery disease (CAD) often undergo revascularization procedures such as coronary artery bypass graft (CABG) surgery or percutaneous transluminal coronary angioplasty (PTCA). This study of a large and diverse sample of elderly, Medicare-insured people found that inappropriate use (or overuse) of PTCA was greater among elderly white men than among other groups. However, this difference did not fully account for racial disparities in overall receipt of revascularization procedures. In fact, after eliminating all inappropriate procedures, there was still a substantial gap in use rates for both CABG surgery and PTCA between blacks and whites, according to the researchers. They analyzed Medicare claims and medical records of 3,960 Medicare enrollees who underwent coronary angiography to diagnose heart problems at 173 hospitals in five States in 1991 and 1992. Of this sample, 1,692 patients underwent 1,711 revascularization procedures within 90 days of angiography. The researchers rated these procedures as appropriate, uncertain, or inappropriate according to criteria determined by an expert panel. Following angiography, rates of PTCA (23 vs. 19 percent) and CABG surgery (29 vs. 17 percent) were significantly higher among white patients than black patients. PTCA and CABG surgery were inappropriately used for 14 percent and 10 percent of patients, respectively.
White patients were more likely than black patients to receive inappropriate PTCA (15 vs. 9 percent). Differences by race were significant among men (20 vs. 8 percent) but not among women. Rates of inappropriate CABG surgery did not differ by race (10 percent in both groups). However, the variation in inappropriate procedures across the five States studied was larger than variation by race or sex (from 4 to 24 percent for PTCA and 0 to 14 percent for CABG surgery). The region in which a patient undergoes angiography may be the most significant determinant of the probability of receiving inappropriate revascularization, conclude the researchers.
Katz, J.N. (2001, September). "Patient preferences and health disparities." Journal of the American Medical Association 286(12), pp. 1506-1509.
Most doctors agree that patients should be involved in decisions regarding their care, especially since individuals vary in how they see the risks and benefits of a treatment. However, patient preferences may explain some of the racial, ethnic, and sexual disparities in use of health care resources that policymakers have pledged to remedy, according to the author of this commentary. Minorities and women seem to be more willing to accept lower functional capacity than white men and to be more risk-averse. For example, men with osteoarthritis choose to undergo joint replacement as soon as they can no longer perform vigorous outdoor activities, whereas women are inclined to forego surgery until they are much more incapacitated (limited to walking from room to room).
Also, blacks with cerebrovascular disease are more averse to the risks of surgery than whites and are more likely than whites to refuse CABG surgery when it is offered as an option. One possible explanation for these differences could be the lingering effects of racial and sex discrimination. Women, blacks, and other groups may receive lifetime messages that subtly discourage or even prevent them from getting the care they need. Perceived higher risks among women and minorities may reflect actual poorer outcomes of care in underserved communities. Thus, patient "preference" for less intensive treatment may in fact represent resignation for the perceived status quo—that interventions are unavailable, unaffordable, ineffective, or unduly risky—even if those perceptions are not accurate.