Unequal Treatment

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Looking Into the Melting Pot 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

Social sciences

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Slide1 : Risa Lavizzo-Mourey

Looking Into the Melting Pot : 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 : 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 : California Population by Race 18% 30% 5% 1%

Disparities in Health Care : 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 : 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 : 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 : Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care IOM COMMITTEE ALAN R. NELSON, M.D. MARTHA N. HILL, Ph.D., R.N. RISA LAVIZZO-MOUREY, M.D., M.B.A. JOSEPH R. BETANCOURT, M.D., M.P.H. M. GREGG BLOCHE, J.D., M.D. W. MICHAEL BYRD, M.D., M.P.H. JOHN F. DOVIDIO, Ph.D. JOSE ESCARCE, M.D., Ph.D. SANDRA ADAMSON FRYHOFER, M.D. THOMAS INUI, Sc.M., M.D. JENNIE R. JOE, PH.D., M.P.H. THOMAS McGUIRE, Ph.D. CAROLINE REYES, M.D. DONALD STEINWACHS, Ph.D. DAVID R. WILLIAMS, Ph.D., M.P.H. HEALTH SCIENCES POLICY BOARD LIASON GLORIA E. SARTO, M.D., Ph.D. IOM PROJECT STAFF BRIAN D. SMEDLEY ADRIENNE Y. SITH DANIEL J. WOOTEN THELMA L. COX SYLVIA I. SALAZAR IOM STAFF ANDREW M. POPE ALDEN CHANG CARLOS GABRIEL PAIGE BALDWIN

Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care : Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care 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. Study Charge:

Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care : Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care 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 Literature Review:

Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care : 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:

Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care : 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 Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care Literature Review:

Slide14 : Non-Minority Minority Difference Clinical Appropriateness and Need Patient Preferences The Operation of Healthcare Systems and the Legal and Regulatory Climate Discrimination: Biases and Prejudice, Stereotyping, and Uncertainty Disparity Quality of Health Care Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care Populations with Equal Access to Health Care

Slide15 :

Summary Of Findings : 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 : 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 services by whites - racial and ethnic disparities in cardiovascular care remain.

Summary of Most Rigorous Studies of Racial and Ethic Differences in Cardiovascular Care : Summary of Most Rigorous Studies of Racial and Ethic Differences in Cardiovascular Care No No Yes Yes No Retrospective Statistical adjustment for type of insurance Clinical and lab data from medical records 1999 Leape et. al. Yes Yes Yes Yes Yes Prospective ESRD Medicare Clinical 1999 Daumit et. al. No No Yes No No Retrospective ESRD Medicare Clinical records and ED logs 1999 Carlisle et. al. Yes No Yes Yes Yes Retrospective VA health care system Clinical 2000 Conigliaro et. al. Find Disparities? Outcomes Appropriateness Disease Severity Adjust for Comorbidity Prospective/ Retrospective Insurance Type of Data Year Author

Slide19 : No Yes No Yes Yes Prospective Statistical adjustment for payment by Medicaid Clinical data 1997 Maynard et. al. Yes No Yes Yes Yes Retrospective, with patient follow-up Not assessed, but patients sampled from both public and private hospitals Clinical and lab data from medical use records 1997 Laouri et. al. Yes No Yes No Yes Prospective Statistical adjustment for type of insurance Clinical 1999 Scirica et. al. Find Disparities? Outcomes Appropriateness Disease Severity Adjust for Comorbidity Prospective/ Retrospective Insurance Type of Data Year Author Yes Yes Yes Yes Yes Prospective Statistical adjustment for type of insurance Clinical data 1997 Peterson et. al.

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 and Ethnic Disparities in Health Care Exist and Are Associated With Worse Outcomes

Racial Differences in the Treatment of Early-Stage Lung Cancer : 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. Racial and Ethnic Disparities in Health Care Exist and Are Associated With Worse Outcomes

The Effect of Patients' Preferences on Racial Differences in Access to Renal Transplantation : Referred for Evaluation Placed on Waiting List or Received Transplant Percentage of Patients Source: Epstein et. al. NEJM 1999. The Effect of Patients' Preferences on Racial Differences in Access to Renal Transplantation

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 non-minorities 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

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 Racial and Ethnic Disparities in Health Care Exist and Are Associated With Worse Outcomes

Racial and Ethnic Disparities in Health Care Exist and Are Associated With Worse Outcomes : Diabetes Care: African Americans are less likely to undergo a measurement of glycosylated hemoglobin, lipid testing, ophthalmologic visits, and influenza vaccinations. Africans Americans were also found to be more likely to use the ER and had fewer total physician visits Disparities were found to exist among various racial/ethnic groups in the number of daily injections given, treatment with insulin, and also with poorer levels of glycemic control No significant disparities found in rate of visits to specialists for diabetes complications, physician testing of blood glucose, or screening for hypertension, retinopathy, and foot problems Racial and Ethnic Disparities in Health Care Exist and Are Associated With Worse Outcomes

Racial and Ethnic Disparities in Health Care Exist and Are Associated With Worse Outcomes : Analgesia: Several studies have documented underuse of analgesics among minority patients both in in-patient and outpatient settings Minority patients get receive inadequate pain medication, even after adjusting for gender, marital status, severity of illness, and time since injury Several studies indicated that cultural/linguistic barriers play a significant role in physician’s ability to detect pain symptoms Some African Americans prescribed more pain medication than Hispanics or Asian Americans Male and female physicians respond differently to patients’ gender and race Racial and Ethnic Disparities in Health Care Exist and Are Associated With Worse Outcomes

Slide29 : 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. 1993; 13(3): 170-176. 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” Annals of Internal Medicine. 1993; 118(8): 593-601. 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. 1987; 25(7): 592-603 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.

Racial Disparity Adjusted for Individual Socioeconomic Factors and Health Plan Effects : Racial Disparity Adjusted for Individual Socioeconomic Factors and Health Plan Effects Adjusted for Socioeconomic Factors Racial Disparity (95% Confidence Interval), % Source: AMA, “Racial Disparities in Quality of Care for Medicare,” JAMA vol 287 no. 10, 2002.

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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. : 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.

Slide34 : “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

What Are Potential Sources of Disparities in 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? : 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 : Hispanics and African Americans More Likely to Feel Treated with Disrespect Source: The Commonwealth Fund 2001 Health Care Quality Survey *Felt disrespected because of ability to pay, to speak English, or of their race/ethnicity. Percent of adults who felt they were treated with disrespect*:

One in Five Have Gone Without Care When Needed Due to Language Obstacles : One in Five Have Gone Without Care When Needed Due to Language Obstacles Spanish Speaking Latino Data 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? 19% Have not sought care when needed due to language barrier

Minorities Face Greater Difficulty in Communicating With Physicians : Minorities Face Greater Difficulty in Communicating With Physicians Percent of adults with one or more communication problems* *Problems include understanding doctor, feeling doctor listened, had questions but did not ask. Source: The Commonwealth Fund 2001 Health Care Quality Survey Base: Adults with health care visit in past two years

Minorities More Likely to Forgo Asking Questions of Their Doctor : Minorities More Likely to Forgo Asking Questions of Their Doctor Source: The Commonwealth Fund 2001 Health Care Quality Survey Base: Adults with health care visit in past two years Percent of adults reporting they had questions which they did not ask on last visit:

Minorities Less Likely toReceive Care at Doctor’s Office : Minorities Less Likely to Receive Care at Doctor’s Office Source: The Commonwealth Fund 2001 Health Care Quality Survey Percent of adults reporting doctor’s office as regular source of care:

Minority Are Less Confident They Will Receive Good-Quality Health Care in the Future : Minority Are Less Confident They Will Receive Good-Quality Health Care in the Future Source: The Commonwealth Fund 2001 Health Care Quality Survey Percent of adults very confident they can get good-quality care in future:

Summary Of Findings : 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 : 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 : 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: A Definition Stereotyping - the process by which people use social categories (e.g. race, sex) in acquiring, processing, and recalling information about others.

Slide48 : Patient Race/Ethnicity Physician Beliefs About Patient (Beliefs about social and behavioral factors and Resources. Includes conscious and unconscious activated beliefs) Physician Interpretation of Symptoms Physician Clinical Decision-Making (Diagnosis, Treatment Recommendation) Treatment Received Patient Behavior in Encounter (eg. Question-asking Self-disclosure, assertiveness) 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? : 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.

The Effect of Patients' Preferences on Racial Differences in Access to Renal TransplantationEpstein et al NEJM 1999;341:1661-1669 : 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 : 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.

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Recommendations:Legal, Regulatory, And Policy : 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 : 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 : 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 : 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 : Recommendations: Research Conduct further research to identify sources of racial and ethnic disparities assess promising intervention strategies Conduct research on barriers to eliminating disparities.

Slide59 : “Reports to health plans about identical disparities could be a powerful lever for change if health plans are able to use this information to target interventions that improve clinical quality for minority enrollees.” -C. Clancy

Slide60 : Actions Must be Sustained and Comprehensive

Slide61 :