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Examples of Racial Disparities in Health Care

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  1. Racial Health Care Disparities Examples of Racial Disparities in Health Care Prepared by: Thomas A. LaVeist, Ph.D. Lydia Isaac, M.S. Center for Health Disparities Solutions Johns Hopkins University Bloomberg School of Public Health

  2. Racial Health Care Disparities Overview • In 2002 the Institute of Medicine published Unequal Treatment which compiled research demonstrating substantial racial and ethnic variation in quality of health care. • Unequal Treatment brought healthcare disparities to the attention of the nation, placing the issue on the forefront of the nation’s health policy agenda. • The purpose of this presentation is to provide an overview of the nature of health care disparities in the United States.

  3. Racial Health Care Disparities Conceptualizing Health Disparities There are two broad categories of health disparities: • Health (STATUS) Disparities • Health (CARE) Disparities

  4. Racial Health Care Disparities Defining Health Disparities • It is important to distinguish between disparities in health status, health care access, quality of health care received and healthcare outcomes. • The cause of each of these are likely related, but they are different phenomena. • Thus, the solutions will likely be different. • This presentation exclusively addresses disparities in health care quality.

  5. Racial Health Care Disparities Model of Health Care DisparitiesThe model views health care disparities as resulting from characteristics of the health care system, the society’s legal and regulatory climate, discrimination, bias, stereotyping and uncertainty. Not all dissimilarities in care are necessarily a disparity. Access to Care Clinical Appropriateness and Need Dissimilarity Non-Minority Patient Preferences Difference Operation of healthcare systems and legal and regulatory Climate Minority Disparity Discrimination: Biases, Stereotyping, and Uncertainty Quality of Care Source: Gomes, C. and McGuire T.G. 2001. Identifying the sources of racial and ethnic disparities in health care use. Unpublished manuscript cited in: IOM,. 2002. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley, B., A. Stith and A. Nelson, eds. Washington DC: National Academy Press

  6. Racial Health Care Disparities Many studies have demonstrated disparities in cardiovascular procedures.

  7. Racial Health Care Disparities Health Care Disparity Percent of patients who obtained a referral Studies of patients who were appropriate candidates for coronary angiography have found race differences in obtaining a referral for this diagnostic procedure. Source: LaVeist TA, Morgan A, Arthur M, Plantholt S, Rubinstein M. Physician Referral patterns and race difference in receipt of coronary angiography. Health Services Research 2002; 37(4):949-962. * Statistically significant difference between African Americans and whites.

  8. Racial Health Care Disparities Health Care Disparity Percent of patients receiving procedure A race disparity in recommendation for coronary revascularization was found among patients in the Veteran Affairs health system, where there are no race differences in ability to pay and providers are paid a salary. Source: Ibrahim SA, Whittle J, Bean-Mayberry B, Kelley ME, Good C, Conigliaro J. Racial/ethnic variations in physician recommendations for cardiac revascularization. Am J Public Health. 2003 Oct;93(10):1689-93. * Statistically significant difference between African Americans and whites.

  9. Racial Health Care Disparities Health Care Disparity Percent of patients receiving abeta blocker prescription Among patients in Medicare managed care who had a myocardial infarction (heart attack), African-American patients are less likely than white patients to receive beta blockers, the established standard of care. Source: Schneider EC, Zaslavsky AM, Epstein AM. Racial disparities in the quality of care for enrollees in Medicare managed care. JAMA. 2002 Mar 13;287(10):1288-94. * Statistically significant difference between African Americans and whites.

  10. Racial Health Care Disparities While the largest body of research has been conducted on quality of care for heart disease, health care disparities have been documented with other diseases as well.

  11. Racial Health Care Disparities There have been many studies of racial health care disparities in cancer.

  12. Racial Health Care Disparities Defining Health Disparities A study of the U.S. national cancer registry (SEER) found that: • African-American and Hispanic men received had longer time intervals between diagnosis and receipt of medical monitoring visit. • Nearly 6% of African-American men and 5% of Hispanic men as compared to 1% of white men did not have any medical monitoring visits or procedures during the 60-month follow up period. Source: Shavers VL, Brown ML, Klabunde CN, Potosky AL, Davis WW, Moul JW, Fahey A. “Race/ethnicity and the intensity of medical monitoring under ‘watchful waiting’ for prostate cancer. Medical Care, March 2004, 42 (3):239-250 N=49901, p<0.001

  13. Racial Health Care Disparities Health Care Disparity Among patients in Medicare managed care (age 65 for older), African-American patients are less likely than white patients to receive breast cancer screening (mammogram). Percent receiving mammography Source: Schneider EC, Zaslavsky AM, Epstein AM. Racial disparities in the quality of care for enrollees in Medicare managed care. JAMA. 2002 Mar 13;287(10):1288-94. * Statistically significant difference between African Americans and whites.

  14. Racial Health Care Disparities Health Care Disparity In a study of race differences in the use of three cancer screening procedures among Medicare patients (age 65 for older), African-American patients are less likely than white patients to receive each procedure. Percent receiving the procedure Source: Cooper GS Koroukian SM “Racial disparities in the use of and indications for colorectal procedures in Medicare beneficiaries” Cancer. 2004 Jan 15;100(2):418-24. * Statistically significant difference between African Americans and whites all categories.

  15. Racial Health Care Disparities Health care disparities have been documented in other conditionsas well.

  16. Racial Health Care Disparities Health Care Disparity:Influenza and Pneumocaccal Vaccination Among respondents to the National Health Interview Study, African-American and Hispanic patients age 65 and older were less likely to receive vaccinations for influenza and pneumonia. Percent vaccinated Source: CDC. Racial/ethnic Disparities in Influenza and Pneumococcal Vaccination Levels among persons aged >65 Years—United States, 1989-2001. MMWR 2003; 51:1019-24

  17. Racial Health Care Disparities Health Care Disparity:Diabetes Co-Morbidities and Eyes Among patients in the Veterans Affairs System African Americans were less likely than whites to have LDL (low-density lipoprotein used to check cholesterol status related with diabetes) checked in past 2 years and to have a dilated eye examination. After taking into consideration facility differences African Americans remained less likely to have LDL testing than whites who received care within the same facility. Percent receiving procedure Source: Heisler M, Smith DM, Hayward RA, Krein SL, Kerr EA. Racial Disparities in Diabetes care processes, outcomes and treatment. Medical Care 2003; 41(11):1221-1232. * Statistically significant difference between African Americans and whites.

  18. Racial Health Care Disparities Two studies of patients presenting to the Emergency Department with fractured limbs found race disparities in use of analgesic medication: Hispanic patients were more than twice as likely to go untreated for pain (relative risk [RR], 2.12; 95%CI, 1.35 to 3.32) (Todd 1993) African-American patients were also more likely to go untreated for pain (RR 1.66, 95% CI, 1.11 to 2.50). (Todd et al. 2000) Kposowa and Tsunsokai (2004) found that Hispanics (OR=.70; CI, 0.52 to 0.93) and African Americans (OR=.67; CI 0.55 to 0.83) had significantly lower odds of being given prescriptions for back pain then their white counterparts. Hispanic and African-American patients less likely than whites to receive pain medication Source: Todd KH, Deaton C, D'Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 2000 Jan;35(1):11-6.Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993 Mar 24-31;269(12):1537-9. Kposowa, AJ and Tsunokai, GT. Searching for relief: racial differences in the treatment of patients with back pain. Race & Society 2002; 5 (2):193-223

  19. Racial Health Care Disparities Health Care Disparity:Osteoporosis Prevention Among patients in a managed care populations black women are less likely than white women to be given a bone marrow density test, even when prior fractures are indicated and less likely to be given any kind or prescription therapy. Percent receiving procedure Source: Mudano A, Casebeer L, Pationo F, Allison J, Weissman N, Kiefe CI, Person S, Gilbert D, Saag K. Racial disparities in Osteoporosis Prevention in a Managed care population. Southern Medical Journal 2003, 96(5): 445-451 * Statistically significant difference between African Americans and whites.

  20. Racial Health Care Disparities Health Care Disparity:Mental Health Percent receiving follow up Among patients in a Medicare managed care population, African Americans are less likely then whites to receive follow up after a mental health related hospitalization. Source: Schneider EC, Zaslavsky AM, Epstein AM. Racial Disparities in quality of care for enrollees in Medicare managed care. JAMA 2002; 287(10):1288-1294 * Statistically significant difference between African Americans and whites.

  21. Racial Health Care Disparities Health Care Disparity:Specialty Mental Health Services Percent with access Poor Latinos have lower access to specialty care than poor non-Latino whites. African Americans classified as not poor were less likely to have access. Source: Alegria, M; Canino G; Vera, M; Calderon, J; Rusch, D and Ortega, A. Inequalities in the use of specialty mental health services among Latinos, African Americans and Non-Latino whites. Psychiatric Services, Dec 2002. 53(12):1547-1555 * Statistically significant difference between African Americans and whites and Latinos and whites.

  22. Racial Health Care Disparities Health Care Disparity:Treatment of major therapeutic procedures • Andrews and Elixhauser found that Hispanics are less likely than non-Hispanic whites to receive major therapeutic procedures for 38% of the 63 conditions they examined. Source: Andrews, RM and Elixhauser, A. Use or major therapeutic procedures: Are Hispanics treated differently than non-Hispanic Whites. Ethnicity and Disease 2000. 10:384-394 N= 1743663 P<.05

  23. Racial Health Care Disparities Health Care Disparity:Asthma Among adults in a managed care organizations fewer African Americans than whites reported care consistent with National Asthma Guidelines. Source: Krishnan JA, Diette GB, Skinner EA, Clark BD, Steinwachs D, Wu AW, Race and Sex differences in consistency of care with national asthma guidelines in managed care organizations. Arch Intern Med 2001; 161: 1660-1668 * Statistically significant difference between African Americans and whites for all measures.

  24. Racial Health Care Disparities Health Care Disparity Percent receiving an eye exam Among patients in Medicare managed care who were diagnosed with diabetes, African-American patients are less likely than white patients to receive an eye exam, an established standard for diabetes care. Source: Schneider EC, Zaslavsky AM, Epstein AM. Racial disparities in the quality of care for enrollees in Medicare managed care. JAMA. 2002 Mar 13;287(10):1288-94. * Statistically significant difference between African Americans and whites.

  25. Racial Health Care Disparities Efforts to address health care disparities most likely to be successful include: Improving quality of primary care services. Improving access to primary care and specialists. Increasing use of health services guidelines in clinical practice. Increasing access to language interpreter services. Improving quality of language interpreter services. Addressing Health Care Disparities

  26. Racial Health Care Disparities Improving Quality of Care One study demonstrated that health care disparities could be reduced by improving quality of care (Sehgal 2003). A quality improvement project involving monitoring of patient outcomes, feedback of performance data, and education of clinicians resulted in an increase in the total percentage of hemodialysis patients receiving the appropriate dose, and a reduction in racial disparities in receiving the appropriate dose. Source: Sehgal AR. Impact of quality improvement efforts on race and sex disparities in hemodialysis. JAMA. 2003 Feb 26;289(8):996-1000

  27. Racial Health Care Disparities Adequate dosage given for hemodialysis pre- and post-quality improvement intervention Source: Sehgal AR. Impact of quality improvement efforts on race and sex disparities in hemodialysis. JAMA. 2003 Feb 26;289(8):996-1000 The gap between African Americans and white patients decreased from 10% to 3%.

  28. Racial Health Care Disparities Access to Specialists • Among cardiac patients who received a consultation with a cardiologist, the race disparity in referral and receipt of coronary angiography was reduced. • Patients who received a cardiology consultation had 5.13 greater odds of receiving coronary angiography. • White patients had 2.2 greater odds of receiving a cardiologist consultation. • White patients had 3.04 greater odds of receiving coronary angiography. • Adjusting for receipt of a cardiologist consultation reduced the race disparity from 3.04 to 2.67 (a 12.2% reduction). Source: LaVeist TA, Arthur M, Morgan A, Plantholt S, Rubinstein M. Explaining racial differences in receipt of coronary angiography: the role of physician referral and physician specialty. Med Care Res Rev. 2003 Dec;60(4):453-67