Over the course of its history, the United States has experienced dramatic improvements in overall health and life expectancy due largely to initiatives in public health, health promotion, disease prevention, and chronic care management. Our ability to prevent, detect, and treat diseases in their early stages has allowed us to target and reduce morbidity and mortality. Despite interventions that have improved the overall health of the majority of Americans, racial and ethnic minorities (blacks, Hispanics/Latinos, Native Americans/Alaskan Natives, Asian/Pacific Islanders) have benefited less from these advances and suffer poorer health outcomes than whites from many major diseases (e.g., cardiovascular disease, cancer, diabetes) in the United States. Research has highlighted that minorities may receive less care and lower quality care than whites, even when confounders such as stage of presentation, comorbidities, and health insurance are controlled. These differences in quality are called racial and ethnic disparities in health care. This chapter will provide an overview of racial and ethnic disparities in health and health care, identify root causes, and provide key recommendations to address them at both the clinical and health system levels.
Nature and Extent of Racial and Ethnic Disparities in Health and Health Care
Minority Americans have poorer health outcomes (compared with whites) from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer, and HIV/AIDS, among others (Fig. e4-1). Multiple factors contribute to these racial and ethnic disparities in health. First and foremost, there is little doubt that social determinants—such as lower levels of education, lower socioeconomic status, inadequate and unsafe housing, racism, and living in close proximity to environmental hazards—disproportionately impact minority populations and thus contribute to poorer health outcomes. For example, three of the five largest landfills in the country are found in black and Latino communities; these environmental hazards have contributed to some of the highest rates of pediatric asthma among these populations. Second, lack of access to care also takes a significant toll, as uninsured individuals are less likely to have a regular source of care, and are more likely to delay seeking care and go without needed care—all resulting in avoidable hospitalizations, emergency hospital care, and adverse health outcomes.
Age-adjusted death rates for selected causes by race and Hispanic origin, 2005. (From U.S. Census Bureau, 2009.)
In addition to the existence of racial and ethnic disparities in health, there are racial/ethnic disparities in the quality of care for those with access to the health care system. For instance, disparities have been found in the treatment of pneumonia (Fig. e4-2) and congestive heart failure (blacks receiving less optimal care than whites when hospitalized for these conditions) and referral to renal transplantation (blacks with end-stage renal disease being referred less often to the transplant list than whites) (Fig. e4-3). Disparities have also been found in the utilization of cardiac diagnostic and therapeutic procedures (blacks being referred less often than whites for cardiac catheterization and bypass grafting), prescription of analgesia for pain control (blacks and Latinos receiving less pain medication than whites for long bone fractures and cancer), and surgical treatment of lung cancer (blacks receiving less curative surgery than whites for non-small-cell lung cancer), among others. Again, many of these disparities occurred even when variations in factors such as insurance status, income, age, comorbid conditions, and symptom expression are taken into account.
Recommended hospital care received by Medicare patients with pneumonia, by race/ethnicity, 2006. Reference population is Medicare beneficiaries with pneumonia who are hospitalized. Composite is calculated by averaging the percentage of the population that received each of the five incorporated components of care. (Adapted from Agency for Health Care Research and Quality: The 2008 National Health Care Disparities Report.)
Referral for evaluation at a transplantation center or placement on a waiting list or receipt of a renal transplantation within 18 months after the start of dialysis among patients who wanted a transplant, according to race and sex. Reference population is 239 black women, 280 white women, 271 black men, and 271 white men. Racial differences were statistically significant among the women and the men (p<.0001 for each comparison). (From JZ Ayanian et al: N Engl J Med 341:1661, 1999.)
Little progress has been made in addressing racial/ethnic disparities in cardiovascular procedures and other advanced surgical procedures, while some progress has been made in eliminating disparities in primary care process measures. Data from the National Registry of Myocardial Infarction found evidence of continued disparities in guideline-based admission, procedural, and discharge therapy use from 1994 to 2006. Compared to whites, black patients were less likely to receive percutaneous coronary intervention/coronary artery bypass grafting (PCI/CABG), a disparity that has shown little improvement since 1994. Further, compared to whites, black patients were less likely to receive lipid-lowering medications at discharge, with a gap that has widened since 1998 (Fig. e4-4). The Centers for Disease Control and Prevention (CDC) analyzed national and state rates of total knee replacement (TKR) for Medicare enrollees for the period 2000 to 2006, stratified by sex, age group, and black or white race. TKR rates overall in the United States increased 58%, with similar increases among whites (61%) and blacks (56%). However, the TKR rate for blacks was 37% lower than the rate for whites in 2000 and 39% lower in 2006—no improvement and even a slight worsening of the disparity (Fig. e4-5). Using data from enrollees in Medicare managed care plans, there is evidence for a narrowing in racial disparities between 1997 and 2003 in several “report card” preventive care measures such as mammography and glucose and cholesterol testing. ...