Chapter 2: Health-Care Disparities: An Overview PDF

Mount Saint Vincent College Access Provided by: Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2e Chapter 2: HealthCare Disparities: An Overview Andrew B. Bindman; Kevin Grumbach; Bruce Guthrie OBJECTIVES Objectives Define the term healthcare disparities. Describe the patient and provider factors that influence access to and the use of healthcare services. Review the characteristics of patients who are at increased risk for healthcare disparities. Identify actions health professionals can take to promote equity in health care. INTRODUCTION The previous chapter defined health disparities as systematic, yet potentially modifiable, differences in health between more and less privileged social groups. This chapter focuses more narrowly on healthcare disparities. After defining this term, the factors that contribute to healthcare disparities, the patients affected by these inequities in access to and quality of care, and strategies to eliminate healthcare disparities are discussed focusing on these issues in the US healthcare setting. QUALITY OF CARE AND HEALTHCARE DISPARITIES The Institute of Medicine has defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”1 Quality can be impaired in different ways, such as overuse, underuse, and misuse. There are major deficiencies on all of these accounts in the quality of care provided by the US healthcare system. For example, there are major deficiencies in the quality of care provided to patients with common chronic diseases: twothirds of patients with high blood pressure are inadequately treated; the majority of patients with diabetes have glycohemoglobin (A1C) levels >7%; and half of the patients hospitalized with congestive heart failure are readmitted within 90 days of discharge. Furthermore, many studies have shown that social status can contribute to the quality of care a patient receives. Social status may alter healthcare professionals’ perceptions of patients’ needs or the way in which patients interact with health services and this in turn may influence the quality of care that is received. In the United States, for example, patients from racial and ethnic minority groups as compared with white patients experience more frequent barriers to care, more limited treatment options when presenting for care, and greater deficits in the quality of care. Such healthcare disparities are seen in association with measures of social status throughout the world. For example, in the United Kingdom, quality of care for patients with diabetes is positively associated with income.2 These healthcare inequities reflect systematic differences in access to or quality of care between more and less privileged groups that cannot be explained by the differences in the need for care or preference for care among the individuals in these groups (Figure 21). Figure 21. Model of healthcare disparities. The Gomes and McGuire model views healthcare disparities as resulting from characteristics of the healthcare Downloaded 2024125 A Your IPclimate, is 63.247.224.45 system, the society’s legal11:45 and regulatory discrimination, bias, stereotyping, and uncertainty. Not all dissimilarities in care are considered a Page 1 / 18 Chapter 2: HealthCare Disparities: An Overview, Andrew B. Bindman; Kevin Grumbach; Bruce Guthrie disparity in care. (Adapted from Gomes C, McGuire T. Identifying the sources of racial and ethnic disparities in healthcare use. Boston, MA: Department ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility of Health Care Policy, Harvard Medical School, 2001. Cited in Smedley BA, Stith A, Nelson A, eds. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academy Press; LaVeist TA, Isaac L. Examples of Racial Disparities in Health Care. Baltimore, MD, These healthcare inequities reflect systematic differences in access to or quality of care between more and less privileged groups that cannot be Mount Saint Vincent College explained by the differences in the need for care or preference for care among the individuals in these groups (Figure 21). Access Provided by: Figure 21. Model of healthcare disparities. The Gomes and McGuire model views healthcare disparities as resulting from characteristics of the healthcare system, the society’s legal and regulatory climate, discrimination, bias, stereotyping, and uncertainty. Not all dissimilarities in care are considered a disparity in care. (Adapted from Gomes C, McGuire T. Identifying the sources of racial and ethnic disparities in healthcare use. Boston, MA: Department of Health Care Policy, Harvard Medical School, 2001. Cited in Smedley BA, Stith A, Nelson A, eds. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academy Press; LaVeist TA, Isaac L. Examples of Racial Disparities in Health Care. Baltimore, MD, 2005.) MEASURES OF QUALITY: PROCESSES OR OUTCOMES OF CARE William Mason and Peter Dixon are admitted to the same hospital on the same day with the same diagnosis: ST wave elevation myocardial infarction (STEMI). Mr. Mason, a white business executive, is promptly rushed to the cardiac catheterization suite where he receives coronary angioplasty and stenting. He is discharged home on aspirin, clopidogrel, a statin, a betablocker, and an angiotensinconverting enzyme inhibitor. Three months later, he is able to garden without experiencing angina. Mr. Dixon, an African American who is an intermittently employed construction worker, is admitted to the coronary care unit but does not receive a coronary arteriogram during his hospital stay. He is discharged home on a statin and calcium channel blocker. Two weeks later, he is readmitted with unstable angina. Applying a qualityofcare framework developed by Donabedian, healthcare disparities can be observed to occur in the processes or outcomes of care.3 Processes of care are the actions healthcare providers take to diagnose, treat, and manage patients’ healthcare needs. Health outcomes, such as morbidity and mortality, are, in part, consequences of these healthcare actions. Mr. Mason had a process of care that was more consistent with evidencebased guidelines than the care received by Mr. Dixon. The inferior process of care received by Mr. Dixon contributed to him having a worse clinical outcome (recurrence of symptomatic coronary heart disease) than Mr. Mason. Of particular concern are the types of healthcare disparities illustrated in this case that contribute to inequities in health outcomes (health disparities). Most investigators agree that healthcare processes have a relatively modest role in explaining health disparities—perhaps explaining only 10–20% of the variation in health outcomes among different groups.4 On the other hand, health disparities resulting from healthcare disparities clearly are in the purview of the people working in the healthcare system and are amenable to change. Health professionals have a particular obligation to eliminate disparities in access to and quality of care that contribute to health inequity for vulnerable populations. BEHAVIORAL MODEL APPLIED TO HEALTHCARE DISPARITIES Downloaded 2024125 11:45 A Your IP is 63.247.224.45 Page 2 / 18 Chapter 2: HealthCare Disparities: An Overview, Andrew B. Bindman; Kevin Grumbach; Bruce Guthrie Why is aMcGraw patient like likely thanTerms a patient like Mr. MasonPolicy to receive highquality care? One of the most frequently used models for ©2024 Hill.Mr. All Dixon Rightsless Reserved. of Use Privacy Notice Accessibility conceptualizing access to care is the behavioral model developed to explain differences in care received by different people or groups of people.5 The behavioral model proposes analyzing the care people receive by looking at three fundamental categories of factors: need, predisposing Most investigators agree that healthcare processes have a relatively modest role in explaining health disparities—perhaps explaining only 10–20% of Mount Saint Vincent College the variation in health outcomes among different groups.4 On the other hand, health disparities resulting from healthcare disparities clearly are in the Access Provided by: purview of the people working in the healthcare system and are amenable to change. Health professionals have a particular obligation to eliminate disparities in access to and quality of care that contribute to health inequity for vulnerable populations. BEHAVIORAL MODEL APPLIED TO HEALTHCARE DISPARITIES Why is a patient like Mr. Dixon less likely than a patient like Mr. Mason to receive highquality care? One of the most frequently used models for conceptualizing access to care is the behavioral model developed to explain differences in care received by different people or groups of people.5 The behavioral model proposes analyzing the care people receive by looking at three fundamental categories of factors: need, predisposing characteristics, and enabling resources. Gelberg and colleagues have revised the model based on their work with homeless populations, proposing a behavioral model for vulnerable populations that includes both traditional categories and vulnerable domains (Table 21).6 Table 21. The Behavioral Model Applied to Vulnerable Populations Need Traditional Domains Vulnerable Domains Perceived health Perceived health General population health conditions Vulnerable population health conditions Evaluated health Evaluated health General population health conditions Vulnerable population health conditions Predisposing Characteristics Traditional Domains Vulnerable Domains Demographics Social structure Age Country of birth Gender Acculturation/Immigration/Literacy Marital status Sexual orientation Veteran status Childhood characteristics Health beliefs Residential history/Homelessness Values concerning health and illness Living conditions Attitudes toward health services Mobility Knowledge about disease Length of time in the community Social structure Criminal behavior/Prison history Ethnicity Victimization Education Mental illness Employment Psychological resources Social networks Substance abuse Occupation Family size Religion Enabling Resources Traditional Domains Vulnerable Domains Personal/Family resources Personal/Family Resources Regular source of care Competing needs Insurance Hunger Income Public benefits Social support Selfhelp skills Perceived barriers to care Ability to negotiate system Community resources Case manager/Conservator Downloaded 2024125 11:45 A Your IP is 63.247.224.45 Residence Transportation Chapter 2: HealthCare Disparities: An Overview, Andrew B. Bindman; Kevin Grumbach; Bruce Guthrie Region ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Telephone Notice Accessibility Health services resources Information sources Community resources Page 3 / 18 characteristics, and enabling resources. Gelberg and colleagues have revised the model based on their work with homeless populations, proposing a 6 Saint Vincent College behavioral model for vulnerable populations that includes both traditional categories and vulnerable domains (Table 21).Mount Access Provided by: Table 21. The Behavioral Model Applied to Vulnerable Populations Need Traditional Domains Vulnerable Domains Perceived health Perceived health General population health conditions Vulnerable population health conditions Evaluated health Evaluated health General population health conditions Vulnerable population health conditions Predisposing Characteristics Traditional Domains Vulnerable Domains Demographics Social structure Age Country of birth Gender Acculturation/Immigration/Literacy Marital status Sexual orientation Veteran status Childhood characteristics Health beliefs Residential history/Homelessness Values concerning health and illness Living conditions Attitudes toward health services Mobility Knowledge about disease Length of time in the community Social structure Criminal behavior/Prison history Ethnicity Victimization Education Mental illness Employment Psychological resources Social networks Substance abuse Occupation Family size Religion Enabling Resources Traditional Domains Vulnerable Domains Personal/Family resources Personal/Family Resources Regular source of care Competing needs Insurance Hunger Income Public benefits Social support Selfhelp skills Perceived barriers to care Ability to negotiate system Community resources Case manager/Conservator Residence Transportation Region Telephone Health services resources Information sources Community resources Crime rates Social services resources Source: Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable populations: Application to medical care use and outcomes for homeless people. Health Serv Res 2000;34:12731302. Downloaded 2024125 11:45 A Your IP is 63.247.224.45 Chapter 2: HealthCare NEED FOR CARE Disparities: An Overview, Andrew B. Bindman; Kevin Grumbach; Bruce Guthrie ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Page 4 / 18 It is axiomatic that people with a greater need for health care, all other things being equal, make greater use of healthcare services. For example, a patient with diabetes has a greater than average need for health care. How much need depends on the severity of the diabetes, and whether there are Social services resources Mount Saint Vincent College Access Provided by: Source: Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable populations: Application to medical care use and outcomes for homeless people. Health Serv Res 2000;34:12731302. NEED FOR CARE It is axiomatic that people with a greater need for health care, all other things being equal, make greater use of healthcare services. For example, a patient with diabetes has a greater than average need for health care. How much need depends on the severity of the diabetes, and whether there are complications or other chronic conditions. Having diabetes per se does not necessarily constitute a disparitiesrelated vulnerability (although it is certainly a risk factor for adverse health outcomes such as heart disease and kidney failure). On the other hand, some clinical conditions may in and of themselves confer a social vulnerability. Prime examples are the socially stigmatizing conditions of learning disabilities, mental illness, and substance use, where the conditions themselves can alter the presentation of illness and where health professionals’ perceptions can contribute to inadequate care. In the preceding case, might there have been some difference between Mr. Dixon’s clinical presentation that made it appear that Mr. Dixon had less clinical need for urgent coronary stenting? PREDISPOSING CHARACTERISTICS Predisposing characteristics refer to health beliefs and culture, careseeking behaviors, trust in health care and other social institutions, and related characteristics that may influence whether, when, and from whom an individual decides to obtain health care when needed. Health education may assist individuals to make wellinformed decisions about using healthcare services. Patients from vulnerable groups such as ethnic minorities may understandably be less trusting of the healthcare system because of personal or collective experiences of social injustice in that setting. One glaring example of this is the Tuskegee Syphilis Experiment.7 Between 1932 and 1972, the US Public Health Service conducted an unethical study at the Tuskegee Institute in Alabama in which A fricanAmerican patients with syphilis were left untreated in order to observe the “natural” progression of syphilis—despite the discovery in the 1940s of penicillin as a highly effective treatment for this infection. African Americans cite the Tuskegee experiment as one reason for concern that medical research may exploit rather than aid them.8 Personal experience of racism contributes even more significantly to mistrust of medical care.9 The human resources deployed in the healthcare system also may contribute to vulnerable patients’ mistrust of the healthcare system and predisposition against using healthcare services. Physicians tend to come from backgrounds that are more privileged and, by virtue of their occupation and income, have a socioeconomic status that on average is higher than that of the population of patients they serve. In the United Kingdom, nearly 60% of medical students come from families in the top 20% of income distribution.10 This can contribute to a sense of social distance between physicians and patients. In addition, the ethnic and cultural backgrounds of many health professionals are different from the characteristics of patients who seek their services. African Americans, Latinos, and Native Americans are underrepresented within the health professional workforce. These three minority groups comprised 26.6% of the US population 16 years and older during 2008–2010, but contributed only 11.3% of the physicians, 17.2% of physician assistants, 15.1% of the registered nurses, 9.0% of the dentists, and 9.8% of pharmacists in the United States.11 African American patients cared for by AfricanAmerican physicians report that their physicians include them more in medical decision making and that they are more satisfied with their care than those who are cared for by non–AfricanAmerican physicians.12 Similarly, Spanishspeaking patients are more satisfied with the care they receive from Spanishspeaking physicians.13 In the United Kingdom, South Asian patients report higher enablement after consultations with physicians with whom they share a language.14 Is it possible that both Mr. Mason and Mr. Dixon were offered urgent cardiac catheterization by their physicians, but Mr. Dixon might have declined to have the procedure performed because of less trust in his physicians and nurses? ENABLING RESOURCES Enabling resources are factors promote to effective health care. These resources may be at the community or personal level. Community Downloaded 2024125 11:45that A Your IP is access 63.247.224.45 Page 5 / 18 Chapter 2: HealthCare AnofOverview, Andrew B. system Bindman; Bruce Guthrie level enabling resources Disparities: are the assets the local healthcare andKevin otherGrumbach; social services. The presence of a community clinic that provides ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility financial assistance for lowincome patients or has interpreters on site are enabling resources that contribute to improving access to care, particularly in lowincome and minority communities where private physicians are less likely to practice.15 The access to care barriers associated with the scarcity to have the procedure performed because of less trust in his physicians and nurses? Mount Saint Vincent College Access Provided by: ENABLING RESOURCES Enabling resources are factors that promote access to effective health care. These resources may be at the community or personal level. Community level enabling resources are the assets of the local healthcare system and other social services. The presence of a community clinic that provides financial assistance for lowincome patients or has interpreters on site are enabling resources that contribute to improving access to care, particularly in lowincome and minority communities where private physicians are less likely to practice.15 The access to care barriers associated with the scarcity of physicians in certain communities can be compounded by the lack of another community “enabler,” reliable transportation. Among the most obvious and fundamental resources that make care easier for a person to access are financial resources: health insurance and the financial means to pay for those healthcare costs not covered by insurance. Lack of health insurance is the single greatest impediment to access to care in the United States and results in unnecessary morbidity for affected individuals and inefficient use of healthcare resources.16 Numerous studies have demonstrated that the uninsured are less likely than those with health insurance to have a regular source of health care, have fewer physician visits, are less likely to receive appropriate preventive services, and are more likely to delay receiving needed medical care. The uninsured are 30% to 50% more likely than privately insured persons to have some deterioration in their health resulting from a chronic condition such as diabetes or asthma that ultimately necessitates a hospitalization that could have been prevented with timely ambulatory care.17 Other research has demonstrated that the uninsured present for care with more advanced stages of cancer, including breast, colorectal, prostate, and skin cancers. Delay in diagnosis is one of the reasons that the uninsured have shorter life expectancies than insured persons. The Institute of Medicine estimates that the agespecific mortality rate is 25% higher in the uninsured than in the privately insured population.18 Not surprisingly, socioeconomic class is a strong predictor of health insurance status. Although 80% of the uninsured live in families with a working adult, the majority of uninsured persons have family incomes falling at the lower end of the income scale. Without financial assistance, these individuals have a limited ability to purchase health insurance coverage and few personal financial resources to allow them to overcome barriers to care associated with the lack of health insurance. Until the passage of the Patient Protection and Affordable Care Act (ACA) in 2010 and its implementation in 2014, many lowincome individuals were eligible only for public coverage on an emergency basis through Medicaid when they became so ill that they required hospitalization. Patients with a chronic disease who only have episodic health insurance coverage for hospitalizations are less likely than those with continuous coverage to receive appropriate treatment in the ambulatory setting that could prevent the pain and suffering associated with complications of their illness.19 The impact of this is apparent in crossnational comparisons with countries that have universal health insurance coverage. For example, the United States has greater disparities in hypertension control across socioeconomic groups than the United Kingdom where health insurance coverage is universal.20 Individuals from racial and ethnic minority groups are more likely than whites to be uninsured, a situation that contributes to racial and ethnic disparities in health care. In 2012, prior to the full implementation of the ACA in the United States, 29% of Latinos, 19% of African Americans, 15% of Asians, and 11% of nonLatino whites were uninsured.21 Variations in average income between racial and ethnic groups explain much, but not all, of the differences in rates of health insurance by race and ethnicity. Might it have been the case that Mr. Dixon was uninsured, and that is why his physicians did not provide the same resourceintensive care received by Mr. Mason? HEALTHCARE DISPARITIES: THE EVIDENCE As discussed in Chapter 1, race/ethnicity and socioeconomic status are powerful predictors of a person’s health status. These same factors are also strongly associated with access to health care and quality of care. There is ample evidence indicating that the differences in care received by Mr. Mason, a highincome white man, and Mr. Dixon, a workingclass AfricanAmerican man, are indicative of pervasive differences in processes of care in the United States based on race/ethnicity and class. Reported disparities in care related to income are worse in the United States than in countries that provide universal health insurance coverage.22 Disparities in health care associated with race and ethnicity are less well documented outside of the United States, making it difficult to compare deficiencies in quality by race and ethnicity in the United States with those that may be present in other countries. Downloaded 2024125 11:45 A Your IP is 63.247.224.45 RACE/ETHNICITY Page 6 / 18 Chapter 2: HealthCare Disparities: An Overview, Andrew B. Bindman; Kevin Grumbach; Bruce Guthrie ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Individuals from minority groups are less likely than whites to have a regular source of care or to have had a doctor visit in the past year. Minorities are also more likely to report delays in receiving needed care. Summarizing a series of national access to care indicators, the Agency for Health Research a highincome white man, and Mr. Dixon, a workingclass AfricanAmerican man, are indicative of pervasive differences in processes of care in the United States based on race/ethnicity and class. Reported disparities in care related to income are worse in the United States thanSaint in countries Mount Vincentthat College provide universal health insurance coverage.22 Disparities in health care associated with race and ethnicity are less well documented of the Access Providedoutside by: United States, making it difficult to compare deficiencies in quality by race and ethnicity in the United States with those that may be present in other countries. RACE/ETHNICITY Individuals from minority groups are less likely than whites to have a regular source of care or to have had a doctor visit in the past year. Minorities are also more likely to report delays in receiving needed care. Summarizing a series of national access to care indicators, the Agency for Health Research and Quality determined that access to care is generally better for nonLatino whites than for members of all other racial and ethnic groups in the United States. The Agency found that when compared with whites on measures of access to care, Latinos scored worse on 62%, Native Americans on 43%, African Americans on 33% and Asians on 24%.23 Even more concerning is the finding that between 2000–2002 and 2010–2011, the number of access measures in which disparities by race and ethnicity improved over time was small. As compared with nonLatino whites, Latinos improved on 3 and declined on 1 of 14 measures. There were no relative improvements or declines for Native Americans over time. African Americans had 1 of 14 access measures and Asians had 2 of 12 access measures improve relative to those for nonLatino whites. The National Healthcare Disparities Report applied quality indicators for preventive, prenatal, neonatal, cancer, and cardiac care, as well as care for chronic conditions such as diabetes, asthma, and HIV/AIDS—measures that extend beyond more general indicators of access to care (e.g., ability to obtain medical care when needed) to assess whether patients received specific services appropriate to their medical needs (Figure 22). Results indicate that in 2010–2011, African Americans received poorer quality of care than whites for more than 40% of the measures. Latinos and Native Americans were also less likely than nonLatino whites to receive a high quality of care. The reasons for these differences remain ill defined, but it has been shown that the US healthcare system’s organization contributes to inequities in health care. For example, minority patients commonly receive care concentrated within a relatively small group of physicians who report that they do not have access to the full range of clinical resources needed to provide quality care.24 Figure 22. In 2010–2011, analysis performed by the Agency for Health Research and Quality as a part of the National Healthcare Disparities Report (2013) found that African Americans (blacks) and Hispanics received worse care than whites for about 40% of quality measures. American Indian/Alaskan Natives (AI/AN) received worse care than whites for onethird of quality measures. Asians received worse care than whites for about onequarter of quality measures but better care than whites for about 30% of quality measures. Poor people received worse care than highincome people for about 60% of quality measures. People with basic or complex activity limitations received worse care than people with neither type of activity limitation for about onethird of quality measures and better care for about onequarter of quality measures. (Based on Figure H.7 Available at: http://www.ahrq.gov/sites/default/files/publications/files/2013highlights.pdf.) Key: AI/AN = American Indian/Alaska Native; n = number of measures. Better = Population received better quality of care than reference group. Same = Population and reference group received about the same quality of care. W o r s e = Population received worse quality of care than reference group. Note: For each measure, the most recent data available to our team were analyzed; for the majority of measures, this represents data from 2010 to 2011. Basic activity limitations include problems with mobility, selfcare, domestic life, or activities that depend on sensory functioning. Complex activity limitations include limitations experienced in work or in community, social, and civic life. Downloaded 2024125 11:45 A Your IP is 63.247.224.45 Chapter 2: HealthCare Disparities: An Overview, Andrew B. Bindman; Kevin Grumbach; Bruce Guthrie ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Page 7 / 18 W o r s e = Population received worse quality of care than reference group. Mount Saint Vincent College Note: For each measure, the most recent data available to our team were analyzed; for the majority of measures, this represents data from 2010 to Access Provided by: 2011. Basic activity limitations include problems with mobility, selfcare, domestic life, or activities that depend on sensory functioning. Complex activity limitations include limitations experienced in work or in community, social, and civic life. HEALTH INSURANCE Do these differences in health care according to race/ethnicity simply reflect the fact that minorities are less likely than whites to have private health insurance? Indeed, differences in access to and quality of care are partly attributable to differences in their health insurance status; however, these differences persist even among individuals with the same type of insurance coverage. For example, within Medicare, a public health insurance program for the elderly that is designed to provide a uniform benefit to its beneficiaries, nonwhites have higher rates of preventable hospitalizations for ambulatory care–sensitive conditions and worse blood pressure, diabetes, and lipid control than white beneficiaries.25,26 Thus, the evidence suggests that patients like Mr. Mason and Mr. Dixon often receive unequal care even when they have the same type of health insurance. SOCIOECONOMIC STATUS Although less research in the United States has examined healthcare disparities associated with an individual’s socioeconomic status, the limited findings are consistent with the notion that those with less social status experience worse quality of care. Findings from the National Healthcare Disparities Report indicate that individuals who are poor or who live in less affluent communities receive fewer preventive care services such as mammograms and dental visits, have higher rates of avoidable hospitalizations, and are more likely to receive inappropriate medications when they see a physician for care.23 These socioeconomic disparities do not seem to be exclusively due to inequities in insurance coverage. For example, even in the United Kingdom where there is universal coverage and health care is free at the point of care, primary care practices serving lowerincome populations have historically had lower quality of preventive care.27,28 NEED AND PREDISPOSING FACTORS If differences in health care according to race/ethnicity and socioeconomic status are not entirely attributable to differences in a dominant “enabling” Downloaded 11:45 Acould Yournon–healthcare IP is 63.247.224.45 factor such as2024125 health insurance, system factors explain these differences? For example, perhaps there are differences in health Page 8 / 18 Chapter 2: HealthCare Disparities: An Overview, Andrew Bindman; Kevin Grumbach; Bruce Guthrie care needs, such as disease severity, or predisposing factors,B.such as patient beliefs and preferences, that might account for the differences found in ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility the National Healthcare Disparities Report. Rather than representing healthcare inequity, might these observed differences in the use of health care simply represent a healthcare system responding reasonably to patients with differing needs and interests? the United Kingdom where there is universal coverage and health care is free at the point of care, primary care practices serving lowerincome Mount Saint Vincent College populations have historically had lower quality of preventive care.27,28 Access Provided by: NEED AND PREDISPOSING FACTORS If differences in health care according to race/ethnicity and socioeconomic status are not entirely attributable to differences in a dominant “enabling” factor such as health insurance, could non–healthcare system factors explain these differences? For example, perhaps there are differences in health care needs, such as disease severity, or predisposing factors, such as patient beliefs and preferences, that might account for the differences found in the National Healthcare Disparities Report. Rather than representing healthcare inequity, might these observed differences in the use of health care simply represent a healthcare system responding reasonably to patients with differing needs and interests? Many of the findings on healthcare differences that appear in the National Healthcare Disparities Report and similar analyses are based on data obtained from patient surveys and administrative records (e.g., billing records) that lack clinical detail about patients’ clinical needs and preferences for care. Some studies have found that the magnitude of the differences in patterns of care is diminished after more thoroughly accounting for differences in the need and preferences for care across patient groups. However, in most cases, the differences in care patterns persist. For example, studies in emergency departments have demonstrated that African Americans and Latinos are less likely than whites to receive opiates for pain management of broken limbs.29,30,31,32 Although these studies did not specifically investigate patient preferences, the findings suggest that physicians’ assessments of patients’ need for care are influenced by not only physiologic information but may also be influenced, consciously or subconsciously, by race or ethnicity. Some studies of patients with acute coronary syndromes, similar to the coronary events experienced by Mr. Mason and Mr. Dixon, have examined detailed information on coronary anatomy and failed to find clinical differences in underlying disease status that would explain the difference in rates of revascularization for AfricanAmerican and white patients.33,34,35 Other studies have compared rates of refusal of recommended major procedures between white and minority patients and found relatively small differences in refusal rates that do not explain the observed differences in the use of these healthcare services across racial and ethnic groups.34,36 Thus, research suggests that differences in rates of patient refusal of invasive procedures rarely explain why patients like Mr. Dixon tend to be less likely than patients like Mr. Mason to undergo coronary revascularization. A final consideration is whether some disparities represent inappropriately excessive care for privileged patients rather than inappropriately low use among vulnerable populations. Several studies have investigated this question for patients with coronary heart disease. Investigators demonstrated that white patients were more likely than AfricanAmerican patients with the same severity of illness to receive coronary artery bypass surgery.37 Comparison of the results of white and AfricanAmerican Medicare patients who received coronary artery bypass surgery against wellestablished clinical criteria has revealed that some white patients were more likely than AfricanAmerican patients to be inappropriately “overtreated” using surgery.38 However, the degree of undertreatment among AfricanAmerican patients was substantially greater than the amount of overtreatment among white patients. Furthermore, one study has shown that AfricanAmerican patients with cardiovascular disease had a higher mortality than white patients because the AfricanAmerican patients received lower use of appropriate surgical treatments.35 Even for lowcost cardiovascular treatments such as prescribing of aspirin, African Americans are less likely to receive appropriate therapy than white patients for all levels of coronary heart disease risk.39 After conducting an extensive literature review of studies comparing the use of healthcare services across racial and ethnic groups, and across a wide spectrum of clinical conditions, the authors of the Institute of Medicine’s Unequal Treatment report concluded that they were “struck by the consistency of the research findings: even among better controlled studies, the vast majority indicated that minorities are less likely than whites to receive needed services, including clinically necessary procedures.”40,41 The report also concluded that most of the differences in care could not be explained by differences in patient preferences or the need for care. They concluded that discrimination and health system characteristics (e.g., lack of interpreters or fragmentation in care) are the main basis for the differences in care that minorities receive. BIAS, STEREOTYPING, AND DISCRIMINATION It is difficult for research to measure directly and objectively the attitudes and motivations underlying the behavior of clinicians. Thus, determining whether healthcare disparities can be attributed to bias, stereotyping, or discrimination tends to be a “diagnosis of exclusion.” The Institute of Medicine’s Unequal Treatment report raises serious concerns that healthcare disparities may result from bias, stereotyping, and potentially racism among people working in the healthcare system, especially given that the lowerquality health care received by racial and ethnic disparities cannot be explained by differences in the need for care, or patient preferences. This sort of bias and stereotyping may be subconscious. These issues are not confined to the United States. For example, there is a report of bias and stereotyping related to patients’ ethnicity among health professionals in the United Kingdom.42 While less studied, it seems likely in the context of other welldocumented social inequities that this sort of bias, stereotyping, and even discrimination also occurs among health professionals in the United States and elsewhere based on other patient characteristics such as gender Downloaded 2024125 11:45 A Your IP is 63.247.224.45 and social class. Page 9 / 18 Chapter 2: HealthCare Disparities: An Overview, Andrew B. Bindman; Kevin Grumbach; Bruce Guthrie ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility ADDRESSING HEALTHCARE DISPARITIES Medicine’s Unequal Treatment report raises serious concerns that healthcare disparities may result from bias, stereotyping, and potentially racism Vincent College among people working in the healthcare system, especially given that the lowerquality health care received by racial andMount ethnic Saint disparities cannot be AccessThese Providedissues by: explained by differences in the need for care, or patient preferences. This sort of bias and stereotyping may be subconscious. are not confined to the United States. For example, there is a report of bias and stereotyping related to patients’ ethnicity among health professionals in the United Kingdom.42 While less studied, it seems likely in the context of other welldocumented social inequities that this sort of bias, stereotyping, and even discrimination also occurs among health professionals in the United States and elsewhere based on other patient characteristics such as gender and social class. ADDRESSING HEALTHCARE DISPARITIES The Institute of Medicine has proposed a broad set of recommendations at the policy, health system, provider, and patient levels that can contribute to eliminating healthcare disparities (see “Core Competency”).40 These recommendations include strategies such as increasing the diversity of the healthcare workforce, structuring payment systems so that they support equitable distribution of healthcare resources, and increasing patient education programs that can empower patients, particularly those from vulnerable groups, to take a greater role in their own medical decision making. This book explores many of the actions that can be taken by health policy decision makers, health professionals, educators, and researchers to eliminate disparities in health care. It is clear that improvement has and can be accomplished. This section summarizes some of the key approaches that health professionals can adopt to reduce healthcare disparities. RECOGNIZE HEALTHCARE DISPARITIES AS A PROBLEM Although many healthcare professional organizations have endorsed a position that all patients, regardless of race, ethnic origin, nationality, primary language, or religion, deserve highquality health care,43 considerable evidence documents that many inequities exist and persist over time in actual practice. One recent study found that physicians, medical students, and members of the public have very different views about healthcare disparities, with physicians being the least likely to agree that there is unfairness in the healthcare system based on a patient’s race or class.44 Thus, one of the first steps in eliminating healthcare disparities is to inform health professionals of the problem so that effective interventions can be established to reduce the inequities. Although progress is slow and uneven, health professionals have demonstrated that they are capable of making adjustments to decrease disparities. For example, the provision of an interpreter for patients with limited English proficiency was once seen as an exception, but it is increasingly common and recognized as a necessary accommodation for patients who require this assistance.45 UNIVERSAL HEALTH INSURANCE After numerous attempts spanning more than a century, the United States through the passage in 2010 of the ACA took a significant step toward universal health insurance coverage.46 The ACA is expected to cover more than 26 million of the estimated 55 million uninsured Americans through either Medicaid or subsidized private insurance, depending on an individual’s income level.47 Extensive research documenting the critical importance of health insurance for gaining access to highquality care contributed to the passage of the law. The Institute of Medicine estimated that a lack of health insurance accounts for 18,000 deaths annually in the United States.18 As noted earlier, minorities and lowincome individuals are particularly likely to be uninsured, and therefore stand to gain the most from this law. Despite its efforts to expand insurance coverage, the ACA falls short of the fully universal coverage that exists in most developed nations. Individuals in the United States who are undocumented immigrants are not eligible for Medicaid or subsidized private insurance coverage under the ACA; most of these individuals and families will therefore remain uninsured and continue to delay seeking care and have unmet healthcare needs. Challenges to implementing the ACA also impede its improving access to care and reducing healthcare disparities. The Supreme Court, in response to challenges to the law’s legitimacy under the Constitution, upheld most of the key components of the ACA but made the expansion of coverage through state administered Medicaid programs optional for states to implement, rather than mandatory as called for by the ACA. As of September 2015, 30 states and the District of Columbia had elected to expand Medicaid coverage under the ACA. Since full implementation of the ACA, about 18 million uninsured people have gained coverage. However, many lowincome Americans living in states that have not elected to expand Medicaid coveragemainly states in the southern region of the United States with large concentrations of economically disadvantaged, uninsured populationscontinue to not benefit from expanded Medicaid coverage. Were all of the states to expand Medicaid coverage, an additional 5 to 6 million uninsured individuals would gain coverage.48 States also face a challenge in educating those who are uninsured about the necessary steps to enroll in health insurance programs. Despite the fact that coverage will either be free or highly subsidized by the federal government, many uninsured individuals may perceive it to be too costly to sign up for coverage. Language and other communication barriers may complicate the ability to educate uninsured individuals about the potential benefits of seeking coverage and the methods for doing so. Some uninsured may falsely believe that they will place their legal immigration status at risk by seeking health insurance coverage (see Chapter 29). Downloaded 2024125 11:45 A Your IP is 63.247.224.45 Page 10way / 18 Participating in advocacyDisparities: efforts to help patients take advantage of new coverage opportunities afforded is one Chapter 2: HealthCare An Overview, Andrew B. Bindman; Kevin Grumbach; Bruce Guthrieby the implementation of the ACA ©2024 McGraw Hill. All Rights Reserved. can Terms Use Privacy Policy Accessibility to address disparities. Health professionals helpofeducate patients about Notice the widened array of public and private insurance programs in the United States, in order to more effectively assist individual patients to navigate the healthcare financing bureaucracy and successfully obtain the coverage they may be entitled to receive (see Chapter 4). Mount Saint Vincent States also face a challenge in educating those who are uninsured about the necessary steps to enroll in health insurance programs. Despite theCollege fact Provided by: that coverage will either be free or highly subsidized by the federal government, many uninsured individuals may perceiveAccess it to be too costly to sign up for coverage. Language and other communication barriers may complicate the ability to educate uninsured individuals about the potential benefits of seeking coverage and the methods for doing so. Some uninsured may falsely believe that they will place their legal immigration status at risk by seeking health insurance coverage (see Chapter 29). Participating in advocacy efforts to help patients take advantage of new coverage opportunities afforded by the implementation of the ACA is one way to address disparities. Health professionals can help educate patients about the widened array of public and private insurance programs in the United States, in order to more effectively assist individual patients to navigate the healthcare financing bureaucracy and successfully obtain the coverage they may be entitled to receive (see Chapter 4). ACCESS AND DELIVERY OF HEALTH SERVICES Universal health insurance is a critical step on the way to achieve healthcare equity, but as the experience of other countries shows, on its own it is unlikely to be enough. Even when insured, vulnerable populations still face deficiencies in the enabling resources that would permit them to obtain equitable health outcomes. Some of these deficiencies may be related to inequalities in the distribution and availability of facilities and technology, such as the preferential location of specialty hospital units in higherincome urban neighborhoods rather than in innercity and rural communities. The quality of healthcare providers available to different groups of patients may vary as well. One analysis of racial differences in Medicare patients’ outcomes after coronary artery bypass graft surgery found that the increased mortality among AfricanAmerican patients compared with whites disappeared after controlling for the quality of the hospital care where patients were obtaining their procedures.49 Healthcare organizations should reach out to surrounding community members and involve community representatives in planning and quality improvement initiatives.43 The organization of the healthcare delivery system may also play a role in reducing healthcare disparities. While it is unclear whether it is due to the financing or the organization of providers in these arrangements, there have been some reports of improvement in healthcare disparities in Medicare and Medicaidmanaged care.50,51 PROVIDERS IN UNDERSERVED AREAS One of the most important of the non–insurancerelated enabling resources is the human resources of the healthcare system: the physicians, nurses, pharmacists, dentists, physician assistants, and many other essential healthcare workers. Healthcare disparities related to human resource enabling factors may result from geographic maldistribution, at least in part. Research has shown that communities in California with a relatively high proportion of minority residents have a much lower supply of physicians, dentists, nurse practitioners, and physician assistants than neighborhoods that have fewer minority residents.15,52,53 This research also has shown that AfricanAmerican and Latino health professionals are much more likely than their white counterparts to work in underserved communities with fewer healthcare resources. Similarly, health professionals who grew up in rural communities are more likely to ultimately practice in rural communities than those who grew up in urban areas. Those who gain coverage as a part of the ACA will increase the demand for healthcare services to address unmet needs due to a previous lack of coverage. This increased demand among the newly insured will stress the capacity of the healthcare system particularly in areas that had high rates of uninsured individuals and an inadequate number of available physicians. One strategy for addressing healthcare disparities related to maldistribution of human resources is to recruit more underrepresented minorities and students from rural backgrounds into the health professions. Adequate payment rates are also an important strategy for increasing the number of practitioners in underserved areas. Medicaid is the dominant payer in most underserved communities; in most states, Medicaid payment rates to physicians and other practitioners are substantially lower than from the fees paid by other insurers.54 Low payment rates in Medicaid discourage physicians from participating in the care of lowincome patients.55 The ACA included a Medicaid payment increase for primary care practitioners to encourage physicians to participate in the Medicaid program, but there are concerns that this policy’s impact may be muted because the payment increases were only in effect during 2013 and 2014. Other countries go even further to support primary care practitioners’ ability to care for the poor. For example, in the United Kingdom, the National Health Service has encouraged physicians to work in less affluent areas by paying higher capitation rates to general practitioners in those communities and by preventing new practices opening in more affluent areas with adequate supply of physicians. Although these policies have produced a nearly equal distribution of general practitioners per 1000 population across neighborhoods, this distribution is still considered by some to be inequitable given the much higher burden of illness and healthcare needs in disadvantaged communities. From the perspective of need, the least affluent therefore can remain underserved even in a universal coverage system (although the degree is typically less extreme than in systems without universal coverage).56,57 Downloaded 2024125 11:45 AAND Your CULTURALLY IP is 63.247.224.45 CLEAR COMMUNICATION COMPETENT CARE Page 11 / 18 Chapter 2: HealthCare Disparities: An Overview, Andrew B. Bindman; Kevin Grumbach; Bruce Guthrie ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Providers’ assessments of patients’ need for care have a subjective component and patients’ preferences for care are somewhat dependent on the information patients receive from providers. Thus, one strategy is to improve health professionals’ cultural competence so that they can more and by preventing new practices opening in more affluent areas with adequate supply of physicians. Although these policies have produced a nearly equal distribution of general practitioners per 1000 population across neighborhoods, this distribution is still considered Mount by some to beVincent inequitable Saint College given the much higher burden of illness and healthcare needs in disadvantaged communities. From the perspective of need, the least affluent Access Provided by: therefore can remain underserved even in a universal coverage system (although the degree is typically less extreme than in systems without universal coverage).56,57 CLEAR COMMUNICATION AND CULTURALLY COMPETENT CARE Providers’ assessments of patients’ need for care have a subjective component and patients’ preferences for care are somewhat dependent on the information patients receive from providers. Thus, one strategy is to improve health professionals’ cultural competence so that they can more effectively evaluate and communicate with diverse patient populations. Increasing the racial, ethnic, and socioeconomic diversity of health professionals and incorporating within health professions training programs curricula on the interpersonal and communications skills necessary for effectively caring for vulnerable populations might accomplish this. GUIDELINES OR STANDARDS IN THE PROCESS OF CARE Implementation of evidencebased clinical guidelines that establish an explicit standard of care that is applied to all patients with the same clinical status or healthcare need appears to be a way to reduce disparities. A study of patients with endstage renal disease found that disparities by race in the adequacy of dialysis treatment diminished after the adoption of an evidencebased treatment guideline.58 This study suggests that guidelines, along with monitoring and feedback of clinical performance benchmarked to an evidencebased guideline, may reduce the degree of subjective judgment and potential bias in clinicians’ clinical decision making, thereby helping to mitigate healthcare disparities. A related and promising approach is for healthcare delivery organizations and payers of care to define explicit guidelines or standards in the process of care for certain conditions, and to monitor processes of care for different patient populations with these conditions based on race/ethnicity, socioeconomic status, or other characteristics to ensure that all groups achieve an equivalently high standard of quality. PAYMENT INCENTIVES Payment incentives tied to healthcare quality can increase accountability in health care. While the focus of these activities is typically on healthcare quality for a population as a whole, there is some research from the United Kingdom, where this approach has been widely adopted in primary care, that pay for performance can contribute to reducing healthcare disparities as well. The United Kingdom implemented a program in 2004 to reward primary care practices based on their quality measured by 48 clinical indicators. The average quality improved in practices over time. While measured quality was initially lower in practices serving less affluent patients, differences were almost eliminated by year 3.59 This indicates that disparities are amenable to intervention, but they require sufficient time to be effective. Eliminating ethnic disparities has proven to be more challenging and they have not narrowed down as rapidly over time as socioeconomic disparities in the United Kingdom’s primary care payforperformance program.60 CONCLUSION The evidence for the existence of healthcare disparities is overwhelming. Disparities exist in access to care and in the quality of care that is delivered once patients access the healthcare system. Recognizing healthcare disparities as a problem is an important first step, but recognition alone will not bring about positive change. The passage of the ACA provides a major opportunity in the United States to decrease healthcare disparities related to financial barriers to care; however, the experience in the United States and internationally suggests that healthcare coverage alone will not be sufficient to fully achieve healthcare equity. KEY CONCEPTS Healthcare disparities reflect systematic differences in access to or quality of care between more and less privileged groups that cannot be explained by the differences in the need for care or preference for care among the individuals in these groups. Minorities and lowincome individuals suffer healthcare disparities in part because they have less access to highquality care. Even among those patients who have accessed care and whose needs have become visible to the healthcare system, there are systematic differences in the receipt of services by groups of patients who vary by characteristics of social privilege. Provider bias, stereotyping, and perhaps even racism may contribute to healthcare disparities. Recognizing healthcare disparities as a problem is an important first step, but providers need to participate in a broad range of changes at the policy, system, and provider level in order to eliminate them. Downloaded 2024125 11:45 A Your IP is 63.247.224.45 Chapter 2: HealthCare Disparities: An Overview, Andrew B. Bindman; Kevin Grumbach; Bruce Guthrie ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility CORE COMPETENCY Institute of Medicine Recommendations for Addressing HealthCare Disparities General Recommendations Page 12 / 18 once patients access the healthcare system. Recognizing healthcare disparities as a problem is an important first step, but recognition alone will not Mount Saint Vincent College bring about positive change. The passage of the ACA provides a major opportunity in the United States to decrease healthcare disparities related to Access Provided by: financial barriers to care; however, the experience in the United States and internationally suggests that healthcare coverage alone will not be sufficient to fully achieve healthcare equity. KEY CONCEPTS Healthcare disparities reflect systematic differences in access to or quality of care between more and less privileged groups that cannot be explained by the differences in the need for care or preference for care among the individuals in these groups. Minorities and lowincome individuals suffer healthcare disparities in part because they have less access to highquality care. Even among those patients who have accessed care and whose needs have become visible to the healthcare system, there are systematic differences in the receipt of services by groups of patients who vary by characteristics of social privilege. Provider bias, stereotyping, and perhaps even racism may contribute to healthcare disparities. Recognizing healthcare disparities as a problem is an important first step, but providers need to participate in a broad range of changes at the policy, system, and provider level in order to eliminate them. CORE COMPETENCY Institute of Medicine Recommendations for Addressing HealthCare Disparities General Recommendations Increase awareness of racial and ethnic disparities in health care among the general public and key stakeholders. Increase healthcare providers’ awareness of disparities. Legal, Regulatory, and Policy Interventions Avoid fragmentation of health plans along socioeconomic lines. Strengthen the stability of patient–provider relationships in publicly funded health plans. Increase the proportion of underrepresented US 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 US Department of Health and Human Services Office for Civil Rights to enforce civil rights laws. Health Systems Interventions Promote the consistency and equity of care by evidencebased guidelines. Structure payment systems to ensure an adequate supply of services to minority patients, and limit provider incentives that may promote disparities. Enhance patient–provider communication and trust by providing financial incentives for practices that reduce barriers and encourage evidencebased practice. Support the use of interpretation services where community needs exist. Support the use of community health workers. Use multidisciplinary treatment and preventive care teams. Patient Education and Empowerment Implement patient education programs to increase patients’ knowledge of how to best access care and participate in treatment decisions. CrossCultural Education in the Health Professions Integrate crosscultural education into the training of all current and future health professionals. Downloaded 2024125 11:45 A Your IP is 63.247.224.45 Data Collection and Monitoring Page 13 / 18 Chapter 2: HealthCare Disparities: An Overview, Andrew B. Bindman; Kevin Grumbach; Bruce Guthrie andHill. report data onReserved. healthcareTerms accessof and use by patients’ race, ethnicity, socioeconomic status, and (where possible) primary ©2024Collect McGraw All Rights Use Privacy Policy Notice Accessibility language. Patient Education and Empowerment Saintdecisions. Vincent College Implement patient education programs to increase patients’ knowledge of how to best access care and participate inMount treatment Access Provided by: CrossCultural Education in the Health Professions Integrate crosscultural education into the training of all current and future health professionals. Data Collection and Monitoring Collect and report data on healthcare access and use by patients’ race, ethnicity, socioeconomic status, and (where possible) primary language. Include measures of racial and ethnic disparities in performance measurement. Monitor progress toward the elimination of healthcare disparities. Report racial and ethnic data by Office of Management and Budget categories, and use subpopulation groups where possible. Research Needs Conduct further research to identify sources of racial and ethnic disparities and assess intervention strategies. Conduct research on ethical issues and other barriers to eliminating disparities. Source: Institute of Medicine. Insuring America’s Health. W ashington, DC: National Academies Press, 2004. DISCUSSION QUESTIONS 1. AfricanAmerican women get breast cancer at the same rate as white women, yet AfricanAmerican women are more likely to die from this disease. Does this represent a healthcare disparity? How would you determine if the problem results from access barriers or the quality of care women receive once they have been diagnosed with cancer? 2. Should you include information on a patient’s race in the history and physical examination? Should you include other information on the patient’s social class such as education, occupation, or income? In what ways do you think it is helpful or harmful for patient care to include this information? 3. Are there healthcare disparities where you practice medicine? How well does your practice setting meet the healthcare needs of everyone in your community? Which groups of patients are excluded? Within the practice, do you think some patients receive suboptimal care? How might you assess your practice to determine if there are healthcare disparities? What policy, system, and provider level changes do you think would be most useful for eliminating healthcare disparities in your practice setting? RESOURCES http://healthequity.pitt.edu/index.html. Minority Health and Health Equity Archive http://www.ahrq.gov. Agency for Health Research and Quality. http://www.amsa.org/hp/uhcres.cfm. American Medical Students Association. http://nursingworld.org/readroom/rwjpaper.htm. American Nurses Association. http://www.kff.org. Kaiser Family Foundation Commission on Medicaid and the Uninsured. http://www.pnhp.org. Physicians for a National Health Program. http://www.census.gov/hhes/www/hlthins/hlthins.html. U.S. Census Bureau. REFERENCES 1. Lohr K, ed. Medicare: A Strategy for Quality Assurance. Washington, DC: Institute of Medicine, National Academies Press, 1990. 2. HippisleyCox J, O’Hanlon S, Coupland C. Association of deprivation, ethnicity, and sex with quality indicators for diabetes: Population based Downloaded 2024125 A Your IPBMJ is 63.247.224.45 survey of 53,000 patients11:45 in primary care. 2004;329:1267–1269. [PubMed: 15548561] Page 14 / 18 Chapter 2: HealthCare Disparities: An Overview, Andrew B. Bindman; Kevin Grumbach; Bruce Guthrie ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility 3. Donabedian A. Evaluating the quality of medical care. Milbank Q 1966;44(Suppl):166–206. 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Health Bindman; Kevin Grumbach; Guthrie 21. DeNavasWalt C, Proctor B, SmithAnJ.Overview, Income, Poverty, Insurance Coverage inBruce the United States: 2012. 2013; Current Population ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Available at http://www.census.gov/prod/2013pubs/p60245.pdf. Accessed August 30, 2014. 22. Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall: How the performance of the U.S. health care system compares Mount Saintpsychiatric Vincent College 19. Harman JS, Manning WG, Lurie N, Christianson JB. Association between interruptions in Medicaid coverage and use of inpatient services. Psychiatr Serv 2003;54:999–1005. [PubMed: 12851437] Access Provided by: 20. Dalton AR, Vamos EP, Harris MJ et al. Impact of universal health insurance coverage on hypertension management: A crossnational study in the United States and England. PloS One 2014;9:e83705. [PubMed: 24416171] 21. DeNavasWalt C, Proctor B, Smith J. Income, Poverty, and Health Insurance Coverage in the United States: 2012. 2013; Current Population Reports. Available at http://www.census.gov/prod/2013pubs/p60245.pdf. Accessed August 30, 2014. 22. Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall: How the performance of the U.S. health care system compares internationally. The Commonwealth Fund. June 2014. Available at http://www.commonwealthfund.org/~/media/files/publications/fund report/2014/jun/1755_davis_mirror_mirror_2014.pdf. 23. Agency for Healthcare Research and Quality. 2013 National Healthcare Disparities Report. 2014. Available at http://www.ahrq.gov/research/findings/nhqrdr/nhdr13/2013nhdr.pdf. 24. Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. Primary care physicians who treat blacks and whites. N Engl J Med Aug 5 2004;351(6):575– 584. [PubMed: 15295050] 25. O’Neil SS, Lake T, Merrill A, Wilson A, Mann DA, Bartnyska LM. Racial disparities in hospitalizations for ambulatory caresensitive conditions. Am J Prev Med 2010;38(4):381–388. [PubMed: 20307806] 26. McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Differences in control of cardiovascular disease and diabetes by race, ethnicity, and education: U.S. trends from 1999 to 2006 and effects of Medicare coverage. Annals Intern Med 2009;150:505–515. 27. Steele RJ, Kostourou I, McClements P et al. Effect of gender, age and deprivation on key performance indicators in a FOBTbased colorectal screening programme. J Med Screen 2010;17:68–74. [PubMed: 20660434] 28. Norbury M, Fawkes N, Guthrie B. Impact of the GP contract on inequalities associated with influenza immunisation: a retrospective population database analysis. Br J Gen Pract 2011;61:e379–385. [PubMed: 21722444] 29. Todd KH, Deaton C, D’Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med 2000;35:11–16. [PubMed: 10613935] 30. Todd KH, Samaroo N, Hoffman JR. 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Shahar E, Folsom AR, Romm FJ et al. Patterns of aspirin use in middleaged adults: The Atherosclerosis Risk in Communities (ARIC) Study. Am 36. Ayanian JZ, Cleary PD, Weissman JS, Epstein AM. The effect of patients’ preferences on racial differences in access to renal transplantation. N Engl J Med 1999;341:1661–1669. [PubMed: 10572155] Mount Saint Vincent College Access Provided by: 37. Ayanian JZ, Udvarhelyi IS, Gatsonis CA, Pashos CL, Epstein AM. Racial differences in the use of revascularization procedures after coronary angiography. JAMA 1993;269:2642–2646. [PubMed: 8487447] 38. Schneider EC, Leape LL, Weissman JS, Piana RN, Gatsonis C, Epstein AM. Racial differences in cardiac revascularization rates: Does “overuse” explain higher rates among white patients? Ann Intern Med 2001;135:328–337. [PubMed: 11529696] 39. Shahar E, Folsom AR, Romm FJ et al. Patterns of aspirin use in middleaged adults: The Atherosclerosis Risk in Communities (ARIC) Study. Am Heart J 1996;131:915–922. 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