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A new Institute of Medicine study says racial and ethnic minorities get lower-quality health care than whites, even when the two groups have the same income and the same access to treatment.
"We were impressed with the depth and breadth of the evidence for the disparity, from preventive care at one end of the spectrum to pain medications at the end of life," says Alan R. Nelson, MD, special adviser to the chief executive officer of the American College of Physicians. Nelson was chair of the IOM study, the results of which have been published in a report titled "Unequal Treatment: Racial and Ethnic Disparities in Healthcare." Studies that didn’t show disparities, including some from the military and from Veterans Administration hospitals, were so rare that they stood out, Nelson adds.
The 598-page report didn’t look specifically at public health. Some of the recommendations the report makes for remedying disparities are already in widespread use in public health settings. For example, the report’s authors urged the use of translational services, and advised offering health care in community-based settings.
Even so, the report’s theme echoes a discussion already taking place in the TB control community. For the past two meetings, the federal Advisory Committee to Eliminate Tuberculosis (ACET) has set aside time on the agenda to broach topics such as "Disparity Issues for African-Americans." ACET discussions have tackled such questions as why high rates of TB remain stubbornly entrenched among poor black Americans and in parts of the country with large populations of poor blacks.
"African-Americans are still at the bottom when it comes to health status," notes Charles Wallace, MPH, PhD, director of the TB Elimination division for the Texas Department of Health. "It’s tied to race; it’s tied to an inability to identify with the patient on the part of the health care provider; and it’s tied to some extent to negligence," he says. Wallace, an African-American, has been among those who have pressed hardest for changes in the ways public-health systems deal with racial minorities.
The IOM report examined health outcomes for a variety of disease entities, from cardiac care to HIV treatment. Almost without exception, outcomes were worse for blacks and other minorities than for whites. For example, cardiac care procedures that are clinically less desirable are prescribed for minorities more often than for whites. Conversely, appropriate procedures and medications are prescribed less often for blacks than for whites. There are also clear disparities in diabetes management and HIV care, the report found.
Factors that lead to the disparities can be divided into three categories, says Nelson: health care systems as a whole; patients; and — as hard as it may be for most physicians to imagine — providers. "I think virtually all doctors are unaware of bias, and many would consciously object to the notion that they are racially prejudiced," Nelson says. Evidence of provider bias is only indirect, he adds, and more research needs to be done on the subject. Instead of overt prejudice, one study cited seems to say physicians respond to racial and gender cues in stereotypical ways.
For example, a study used trained actors to mimic various symptoms. When actors sought "help" from physicians, female providers generally prescribed higher doses of analgesic for black "patients" than for white ones. All physicians were less likely to recommend cardiac catheterization for black female "patients" than for both white and black male "patients."
The report says chances for equal treatment are greatest "when providers are using clear practice guidelines and when a good deal of certainty exists about the course of action," notes Nelson. Chances for equal treatment worsen when there is a need for interpretation services, when patients distrust providers, or when physicians use stereotypes about minority patients to reach a decision, Nelson says.
The first place to start is to educate providers about the health care gap, he notes. It’s also important to train providers in better communication, provide more formal training in recognizing and dealing with biases, and increase the number of minority providers, he says. Having more minority providers yields increased minority patient satisfaction and may also lead to better compliance and improved outcomes, the report says.
Wallace says he’s not surprised by the IOM study’s findings. "I’m a living witness," he says. "If I didn’t have a little medical knowledge, and the guts to question some of the procedures that have been prescribed for me, I’d fall through the cracks myself."
[Editor’s note: To read or order the IOM study report on-line, go to www.nap.edu. To order by phone, call (800) 624-6242 or (202) 334-3313.]