Risa Lavizzo-Mourey. Looking Into the Melting Pot Nearly one in every ten U.S. residents were born...

Risa Lavizzo-MoureyRisa Lavizzo-Mourey

Looking Into the Melting PotLooking Into the Melting PotNearly one in every ten U.S. residents were born Nearly one in every ten U.S. residents were born elsewhere, the highest percentage of foreign born elsewhere, the highest percentage of foreign born

residents since the 1930’s.residents since the 1930’s.

Look Ahead to an America of All Look Ahead to an America of All ‘Minorities’ in a Few Years‘Minorities’ in a Few YearsWith changing immigration, no group will be a majority.With changing immigration, no group will be a majority.

California Population by RaceCalifornia Population by Race

LatinoWhiteBlackAsianAm Indian18%18%

30%30%

5%5%

1%1%

Disparities in Health CareDisparities in Health Care• African Americans are 50% less likely to get heart African Americans are 50% less likely to get heart

bypass surgerybypass surgery

• African Americans are 25% less likely to get pain African Americans are 25% less likely to get pain medicationmedication

• African Americans are 54% as likely to get colon African Americans are 54% as likely to get colon cancer screening procedurescancer screening procedures

• African Americans with lymphoma are 34-45% as African Americans with lymphoma are 34-45% as likely to undergo a bone marrow transplantlikely to undergo a bone marrow transplant

• African Americans are 12.7% less likely to get African Americans are 12.7% less likely to get surgery for lung cancersurgery for lung cancer

The Effect of Race and Sex on Physicians'The Effect of Race and Sex on Physicians'Recommendations for Cardiac CatheterizationRecommendations for Cardiac Catheterization

• 720 physicians viewed 720 physicians viewed recorded interviews recorded interviews

• Reviewed data about Reviewed data about a hypothetical patient a hypothetical patient

• The physicians then made The physicians then made recommendations about recommendations about that patient's care that patient's care

Source: Schulman et.al. NEJM 1999;340:618.

The Effect of Race and Sex on Physicians'The Effect of Race and Sex on Physicians'Recommendations for Cardiac CatheterizationRecommendations for Cardiac Catheterization

• Women (OR =0.60) and blacks (OR =0.60) were less Women (OR =0.60) and blacks (OR =0.60) were less likely to be referred for cardiac catheterization than likely to be referred for cardiac catheterization than men and whites, respectively. men and whites, respectively.

• Black women were significantly less likely to be Black women were significantly less likely to be

referred for catheterization than white men (OR= 0.4)referred for catheterization than white men (OR= 0.4)

Source: Schulman et. al., NEJM 1999;340:618.

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

IOM COMMITTEE

ALAN R. NELSON, M.D.

MARTHA N. HILL, Ph.D., R.N.

RISA LAVIZZO-MOUREY, M.D., M.B.A.

JOSEPH R. BETANCOURT, M.D., M.P.H.

M. GREGG BLOCHE, J.D., M.D.

W. MICHAEL BYRD, M.D., M.P.H.

JOHN F. DOVIDIO, Ph.D.

JOSE ESCARCE, M.D., Ph.D.

SANDRA ADAMSON FRYHOFER, M.D.

THOMAS INUI, Sc.M., M.D.

JENNIE R. JOE, PH.D., M.P.H.

THOMAS McGUIRE, Ph.D.

CAROLINE REYES, M.D.

DONALD STEINWACHS, Ph.D.

DAVID R. WILLIAMS, Ph.D., M.P.H.

HEALTH SCIENCES POLICY BOARD LIASON

GLORIA E. SARTO, M.D., Ph.D.

IOM PROJECT STAFF

BRIAN D. SMEDLEY

ADRIENNE Y. SITH

DANIEL J. WOOTEN

THELMA L. COX

SYLVIA I. SALAZAR

IOM STAFF

ANDREW M. POPE

ALDEN CHANG

CARLOS GABRIEL

PAIGE BALDWIN

Committee on Understanding Committee on Understanding and Eliminating Racial and Ethnic and Eliminating Racial and Ethnic

Disparities in Health CareDisparities in Health Care

• Assess the extent of racial and ethnic differences in Assess the extent of racial and ethnic differences in healthcare that are not otherwise attributable to known healthcare that are not otherwise attributable to known factors such as access to care (e.g., ability to pay or factors such as access to care (e.g., ability to pay or insurance coverage);insurance coverage);

• Evaluate potential sources of racial and ethnic disparities Evaluate potential sources of racial and ethnic disparities in healthcare, including the role of bias, discrimination, in healthcare, including the role of bias, discrimination, and stereotyping at the individual (provider and patient), and stereotyping at the individual (provider and patient), institutional, and health system levels; and,institutional, and health system levels; and,

• Provide recommendations regarding interventions to Provide recommendations regarding interventions to eliminate healthcare disparities.eliminate healthcare disparities.

Study Charge:Study Charge:

Committee on UnderstandingCommittee on Understanding and Eliminating Racial and Ethnic and Eliminating Racial and Ethnic


• Literature reviewLiterature review

• Public workshopsPublic workshops

• Focus groupsFocus groups

Methods:Methods:



• Literature searches via PUBMED or MEDLINELiterature searches via PUBMED or MEDLINE– Keywords:Keywords:

• Race, racial, ethnicity, minority/ies, groups, African Race, racial, ethnicity, minority/ies, groups, African American, Black, American Indian, Alaska Native, Native American, Black, American Indian, Alaska Native, Native American, Asian, Pacific Islander, Hispanic LatinoAmerican, Asian, Pacific Islander, Hispanic Latino

• Differences, disparities, careDifferences, disparities, care

• Cardiac, coronary, cancer, asthma, HIV, AIDS, pediatric, Cardiac, coronary, cancer, asthma, HIV, AIDS, pediatric, children, mental health, psychiatric, eye, ophthalmic, children, mental health, psychiatric, eye, ophthalmic, glaucoma, emergency, diabetes, renal, gall bladder, ICU, glaucoma, emergency, diabetes, renal, gall bladder, ICU, peripheral vascular, transplant, organ, cesarean, prenatal, hip, peripheral vascular, transplant, organ, cesarean, prenatal, hip, hypertension, injury, surgery/surgical, knee, pain, procedure, hypertension, injury, surgery/surgical, knee, pain, procedure, treatment, diagnostictreatment, diagnostic

Literature Review:Literature Review:

• Only studies Only studies

– control or adjustment for racial and ethnic control or adjustment for racial and ethnic differences in insurance statusdifferences in insurance status

• Other “threshold” criteria included:Other “threshold” criteria included:

– primary purpose was to examine variation in primary purpose was to examine variation in medical care by race and ethnicitymedical care by race and ethnicity



Literature Review:Literature Review:

• The committee ranked studies on several criteria:The committee ranked studies on several criteria:– Control of insurance statusControl of insurance status– Patient socioeconomic statusPatient socioeconomic status– Clinical dataClinical data– Prospective or retrospective data collectionProspective or retrospective data collection– Appropriate control for patient co-morbid conditionsAppropriate control for patient co-morbid conditions– Control for racial differences in disease severity or stage Control for racial differences in disease severity or stage

of illness at presentationof illness at presentation– Patients’ appropriateness for proceduresPatients’ appropriateness for procedures– Rates of refusal or patient preferencesRates of refusal or patient preferences


Disparities in Health CareDisparities in Health Care Literature Review:Literature Review:

Non

-Min

orit

y

Min

orit

yDifference

Clinical Appropriateness and Need

Patient Preferences

The Operation of Healthcare Systems and the Legal and

Regulatory Climate

Discrimination: Biases and Prejudice, Stereotyping,

and Uncertainty

Disparity

Qu

alit

y of

Hea

l th

Car

e

Differences, Disparities, and Differences, Disparities, and Discrimination: Populations with Equal Discrimination: Populations with Equal

Access to Health CareAccess to Health Care

Populations with Equal Access to Health Care

Summary Of FindingsSummary Of Findings

• Racial and ethnic disparities in health care exist Racial and ethnic disparities in health care exist

and, because they are associated with worse and, because they are associated with worse

outcomes in many cases, are unacceptable.outcomes in many cases, are unacceptable.

• Racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life.

• Many sources – including health systems, health care providers, patients, and utilization managers – contribute to racial and ethnic disparities in health care.

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

Cardiovascular care:Cardiovascular care:• The preponderance of studies find that even after The preponderance of studies find that even after

adjustment for many potentially confounding factors---adjustment for many potentially confounding factors---including racial differences in access to care, disease including racial differences in access to care, disease severity, site of care (e.g. geographic variation or type severity, site of care (e.g. geographic variation or type of hospital or clinic), disease prevalence, comorbidity of hospital or clinic), disease prevalence, comorbidity or clinical characteristics, refusal rates, and overuse of or clinical characteristics, refusal rates, and overuse of

services by whites -services by whites - racial and ethnic racial and ethnic disparities in cardiovascular care remain.disparities in cardiovascular care remain.

Summary of Most Rigorous Studies of Racial Summary of Most Rigorous Studies of Racial and Ethic Differences in Cardiovascular Careand Ethic Differences in Cardiovascular Care

NoNoYesYesNoRetrospectiveStatistical adjustment for type of insurance

Clinical and lab

data from medical records

1999Leape

et. al.

YesYesYesYesYesProspectiveESRD Medicare

Clinical1999Daumit et. al.

NoNoYesNoNoRetrospectiveESRD

Medicare

Clinical records and ED

logs

1999Carlisle

et. al.

YesNoYesYesYesRetrospectiveVA health care

system

Clinical2000Conigliaro

et. al.

Find Disparities

?

OutcomesAppropriatenessDisease Severity

Adjust for Comorbidity

Prospective/

Retrospective

InsuranceType of Data

YearAuthor

NoYesNoYesYesProspectiveStatistical adjustment for payment by Medicaid

Clinical data

1997Maynard

et. al.

YesNoYesYesYesRetrospective, with patient

follow-up

Not assessed, but patients

sampled from both public and

private hospitals

Clinical and lab

data from

medical use

records

1997Laouri

et. al.

YesNoYesNoYesProspectiveStatistical adjustment for type of insurance

Clinical1999Scirica

et. al.

Find Disparities?

OutcomesAppropriatenessDisease Severity

Adjust for Comorbidity

Prospective/

Retrospective

InsuranceType of Data

YearAuthor

YesYesYesYesYesProspectiveStatistical

adjustment for type of insurance

Clinical data

1997Peterson

et. al.

Cancer Treatment:Cancer Treatment:

• Less clear and consistent than studies of Less clear and consistent than studies of

cardiac carecardiac care

• Several studies demonstrate significant racial Several studies demonstrate significant racial

differences in the receipt of appropriate cancer differences in the receipt of appropriate cancer

treatments and analgesicstreatments and analgesics


•

Racial Differences in the Treatment of Racial Differences in the Treatment of

Early-Stage Lung CancerEarly-Stage Lung Cancer

Source: Bach, Peter B. Et al. NEJM 1999;341:1198-205

Renal Transplantation:Renal Transplantation:

• African-American patients (and in some instances, other African-American patients (and in some instances, other ethnic minority patients) are ethnic minority patients) are

– less likely to be judged as appropriate for transplantationless likely to be judged as appropriate for transplantation

– less likely to appear on transplantation waiting listsless likely to appear on transplantation waiting lists

– less likely to undergo transplantation procedures, even less likely to undergo transplantation procedures, even after patients’ insurance status and other factors are after patients’ insurance status and other factors are considered.considered.


Referred for Evaluation

Placed on Waiting Listor Received Transplant

Per

cen

tage

of

Pat

ien

ts

Source: Epstein et. al. NEJM 1999.

The Effect of Patients' Preferences on The Effect of Patients' Preferences on Racial Differences in Access to Renal Racial Differences in Access to Renal

TransplantationTransplantation

59.6%

80.3%

57.9%

82.2%

40.3%

68.9%

40.6%

67.9%

0%10%

20%

30%

40%

50%

60%

70%

80%90%

Black women White women Black men White men

HIV/AIDS Treatment:HIV/AIDS Treatment:

• African Americans areAfrican Americans are

– less likely to receive antiretroviral therapyless likely to receive antiretroviral therapy

– less likely to receive prophylaxis for pneumocystis less likely to receive prophylaxis for pneumocystis pneumoniapneumonia

– less likely to receive protease inhibitors than non-less likely to receive protease inhibitors than non-minorities with HIVminorities with HIV

• These disparities remain even after adjusting for age, These disparities remain even after adjusting for age, gender, education, and insurance coverage.gender, education, and insurance coverage.


Asthma Treatment:Asthma Treatment: • African Americans are African Americans are

– more likely to recieve care in ER and to be hospitalized more likely to recieve care in ER and to be hospitalized

– less likely to be seen by an asthma specialist less likely to be seen by an asthma specialist

– more likely to use corticosteroidsmore likely to use corticosteroids

– less likely to be prescribed anticholinergic medications. less likely to be prescribed anticholinergic medications.

• Despite high levels of access, African Americans had lower disease-Despite high levels of access, African Americans had lower disease-related quality of life scoresrelated quality of life scores

• Findings of disparities in asthma care are mixed, and may vary as a Findings of disparities in asthma care are mixed, and may vary as a function of the education level of patient populations studiedfunction of the education level of patient populations studied


1.Ayanian, J,Z., “Race, Class, and the Quality of Medical Care” JAMA 1994; 271(15): 1207-12082.Ayanian, J.Z. et al, “Racial Differences in the Use of Revascularization Procedures After Coronary Angiography” JAMA 1993; 269(20): 2642-2646

3.Escarce, J.J. et al, Racial differences in the Elderly’s Use of Medical Procedures and Diagnostic Tests” American Journal of Public Health. 1993; 83(7): 948-954.

4.Franks, A.L. et al, “Racial differences in the use of invasive coronary procedures after acute myocardial infarction in Medicare beneficiaries” Ethnicity and Disease 1993; 3(3): 213-220

5.Gibaldi, M., “Ethnic differences in the assessment and treatment of disease” Pharmacotherapy. 1993; 13(3): 170-176.

6.Giles, w.H. et al “Race and Sex Differences in Rates of Invasive Cardiac Procedures in U.S. Hospitals” Archives of Internal Medicine. 1995; 155: 318-324

7.Goldberg K.C. et al, “Racial and Community Factors Influencing Coronary Artery Bypass Graft Surgery Rates for all 1986 Medicare Patients” JAMA. 1992; 267(11): 1473-1477.

8.Hannan, EL and H Kilburn, JF O’Donnell, G Lukacik, EP Shields. “Interracial Access to Selected Cardiac Procedures for Patients Hospitalized with Coronary Artery Disease in New York State” Medical Care. 1991; 29(5): 430-441

9.Johnson, P.A. et al, “Effect of race on the Presentation and Management of Patients with Acute Chest Pain” Annals of Internal Medicine. 1993; 118(8): 593-601.

10.Kahn, K.L. et al, “Health care for Black and Poor Hospitalized Medicare Patients” JAMA 1994; 271(15): 1169-1174

11.Maynard, C. et al, “Blacks in the Coronary Artery Surgery Study (CASS):Race and Clinical Decision Making” American Journal of Public Health 1986; 76(12): 1446-1448.

12.McBean AM, Warren JL, Babish JD. “Continuing Differences in the rates of percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery between elderly black and white Medicare beneficiaries” American Heart Journal 1994; 127(2): 287-295

13.Oberman, A. and Cutter, G., “Issues in the natural history and treatment of coronary heart disease in black populations: Surgical treatment

14.Soucie, J. M. et al, “Race and sex differences in the identification of candidates for rental transplantation” American Journal of Kidney Diseases 1992; 19(5): 414-419

15.Wenneker M.B. and Epstein, A.M. “Racial Inequalities in the Use of Procedures for Patients With Ischemic Heart Disease in Massachusetts” JAMA. 1989; 261(2): 253-257

16.Wilson, MG, DS May, JJ Kelly. “Racial Differences in the Use of Total Knee Arthroplasty for Osteoarthritis Among Older Americans” Ethnicity & Disease. 1994; 4: 57-67

17.Yergen, J. etal “Relationship Between Patient Race and the Intensity of Hospital Services” Medical Care. 1987; 25(7): 592-603

18.BachP. et al Racial Differences in the Treatment of Early Stage Lung Cancer NEJM 1999;341:1198-205

19. Care needs of terminally ill nursing home residents, JAGS 46:1091-1096, 1998

20. 20. The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization Schulman et al N. E J. M 1999;340:61821.24.25.26.


• Racial and ethnic disparities in health care exist and, because they are associated with worse outcomes in many cases, are unacceptable.

• Racial and ethnic disparities in health care occur Racial and ethnic disparities in health care occur in the context of broader historic and in the context of broader historic and contemporary social and economic inequality, contemporary social and economic inequality, and evidence of persistent racial and ethnic and evidence of persistent racial and ethnic discrimination in many sectors of American life.discrimination in many sectors of American life.

• Many sources – including health systems, health care providers, patients, and utilization managers – contribute to racial and ethnic disparities in health care.

Byrd WM, Clayton LA. 2000. Byrd WM, Clayton LA. 2000. An American Health Dilemma. An American Health Dilemma. Volume 1. Volume 1.

A Medical History of African Americans and A Medical History of African Americans and the Problem of Race: Beginnings to 1900. the Problem of Race: Beginnings to 1900.

New York, RoutledgeNew York, Routledge..

“I have often contemplated whether, as a physician, I can

rise above the attitudes of the society in which I was born

and live and the city in which I practice. Can I learn to see

through the faces of the people I treat and deliver to every

one of them the highest quality care I have been trained to

provide? Can I assist my patients in negotiating the racial

prejudice that lines the road between my office and the

rest of the health care system?” -Neil Calman, MD

“I have often contemplated whether, as a physician, I can

rise above the attitudes of the society in which I was born

and live and the city in which I practice. Can I learn to see

through the faces of the people I treat and deliver to every

one of them the highest quality care I have been trained to

provide? Can I assist my patients in negotiating the racial

prejudice that lines the road between my office and the

rest of the health care system?” -Neil Calman, MD


• Racial and ethnic disparities in health care exist and, because they are associated with worse outcomes in many cases, are unacceptable.

• Racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life.

• Many sources – including health systems, health Many sources – including health systems, health care providers, patients, and utilization managers – care providers, patients, and utilization managers – contribute to racial and ethnic disparities in health contribute to racial and ethnic disparities in health care.care.

What Are Potential Sources of What Are Potential Sources of Disparities in Care?Disparities in Care?

• Health systems-level factors: financing, Health systems-level factors: financing, structure of care; cultural and linguistic structure of care; cultural and linguistic barriersbarriers

• Patient-level factors: patient preferences Patient-level factors: patient preferences and behaviorsand behaviors

• Disparities arising from the clinical Disparities arising from the clinical encounterencounter

Western Bioethics on the Navajo Western Bioethics on the Navajo Reservation - Benefit or Harm?Reservation - Benefit or Harm?

JA Carres and JA Carres and

LA RhodesLA Rhodes

JAMA 1995; 274: 826-829JAMA 1995; 274: 826-829

Hispanics and African Americans More Hispanics and African Americans More Likely to Feel Treated with DisrespectLikely to Feel Treated with Disrespect

11%9%

16%18%

13%

0%

10%

20%

Total White AfricanAmerican

Hispanic AsianAmerican

Source: The Commonwealth Fund 2001 Health Care Quality Survey

*Felt disrespected because of ability to pay, to speak English, or of their race/ethnicity.

Percent of adults who felt they were treated with disrespect*:

One in Five Have Gone Without Care One in Five Have Gone Without Care When Needed Due to Language ObstaclesWhen Needed Due to Language Obstacles

Spanish Speaking Latino Data

HQ11: In the course of the past year, how many times were you sick, but decided not to visit a doctor because the doctor didn’t speak Spanish or have an interpreter?

19% Have not sought care when needed due to language barrier

Minorities Face Greater Difficulty in Minorities Face Greater Difficulty in Communicating With PhysiciansCommunicating With Physicians

19%16%

23%

33%

27%

0%

20%

40%



Percent of adults with one or more communication problems*

*Problems include understanding doctor, feeling doctor listened, had questions but did not ask.Source: The Commonwealth Fund 2001 Health Care Quality Survey

Base: Adults with health care visit in past two years

Minorities More Likely to Forgo Minorities More Likely to Forgo Asking Questions of Their DoctorAsking Questions of Their Doctor

12%10%

13%

19%

14%

0%

5%

10%

15%

20%

25%




Base: Adults with health care visit in past two years

Percent of adults reporting they had questions which

they did not ask on last visit:

Minorities Less Likely toMinorities Less Likely toReceive Care at Doctor’s OfficeReceive Care at Doctor’s Office

76% 80%

66%59%

73%

0%

50%

100%




Percent of adults reporting doctor’s office as regular source of care:

Minority Are Less Confident They Will Minority Are Less Confident They Will Receive Good-Quality Health CareReceive Good-Quality Health Care

in the Future in the Future

49% 52%47%

40% 39%

0%

20%

40%

60%




Percent of adults very confident they can get good-quality care in future:


• Bias, stereotyping, prejudice, and clinical Bias, stereotyping, prejudice, and clinical

uncertainty on the part of healthcare providers uncertainty on the part of healthcare providers

may contribute to racial and ethnic disparities in may contribute to racial and ethnic disparities in

healthcare. healthcare.

• Racial and ethnic minority patients are more likely than white patients to refuse treatment, but differences in refusal rates are generally small, and minority patient refusal does not fully explain healthcare disparities.

Disparities in the Clinical Encounter: Disparities in the Clinical Encounter: The Core ParadoxThe Core Paradox

• Bias Bias

No evidence suggests that providers are more likely than the No evidence suggests that providers are more likely than the general public to express biases, but some evidence suggests general public to express biases, but some evidence suggests that unconscious biases may existthat unconscious biases may exist

• Uncertainty Uncertainty

A plausible hypothesis, particularly when providers treat A plausible hypothesis, particularly when providers treat patients that are dissimilar in cultural or linguistic backgroundpatients that are dissimilar in cultural or linguistic background

• Stereotyping Stereotyping

Evidence suggests that physicians, like everyone else, use these Evidence suggests that physicians, like everyone else, use these ‘cognitive shortcuts’‘cognitive shortcuts’

Disparities in the Clinical Encounter: Disparities in the Clinical Encounter: The Core ParadoxThe Core Paradox

How could well-meaning and highly educated How could well-meaning and highly educated

health professionals, working in their usual health professionals, working in their usual

circumstances with diverse populations of circumstances with diverse populations of

patients, create a pattern of care that appears to patients, create a pattern of care that appears to

be discriminatory?be discriminatory?

Stereotyping: A DefinitionStereotyping: A Definition

Stereotyping - the process by which people Stereotyping - the process by which people

use social categories (e.g. race, sex) in use social categories (e.g. race, sex) in

acquiring, processing, and recalling acquiring, processing, and recalling

information about others.information about others.

Patien

t

Race/E

thn

icity

Physician

Beliefs

About Patient(Beliefs about

social and

behavioral

factors and

Resources.

Includes

conscious and

unconscious

activated beliefs)

Physician

Interpretation

of Symptoms

Physician

Clinical

Decision-Making

(Diagnosis, Treatment

Recommendation)

Treatment

Received

Patient Behavior in

Encounter

(eg. Question-asking

Self-disclosure,

assertiveness)

Provider Interpersonal

Behavior

(eg. Participatory style,

warmth, content, information

giving, question-asking)

Patient

Satisfaction

Patient Cognitive & Affective States

(eg. Acceptance of medical advice, attitude, self-efficacy, intention)

Patient Behaviors

(eg. Adherence,

self-management,

utilization)

Stereotyping: When Is It in Action?Stereotyping: When Is It in Action?

Situations characterized by:Situations characterized by:• time pressure time pressure • resource constraintsresource constraints• high cognitive demand high cognitive demand

Promote stereotyping due to the need for cognitivePromote stereotyping due to the need for cognitive‘‘shortcuts’ and lack of full information.shortcuts’ and lack of full information.


• Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare.

• Racial and ethnic minority patients are more likely Racial and ethnic minority patients are more likely

than white patients to refuse treatment, but differences than white patients to refuse treatment, but differences

in refusal rates are generally small, and minority in refusal rates are generally small, and minority

patient refusal does not fully explain healthcare patient refusal does not fully explain healthcare

disparities.disparities.

The Effect of Patients' Preferences on The Effect of Patients' Preferences on Racial Differences in Access to Renal Racial Differences in Access to Renal

TransplantationTransplantationEpstein et al NEJM 1999;Epstein et al NEJM 1999;

341:341:1661-16691661-1669

Recommendations:Recommendations:Actions Must be Sustained and Actions Must be Sustained and

ComprehensiveComprehensive

• Increase awareness of racial and ethnic Increase awareness of racial and ethnic

disparities in health care among the general disparities in health care among the general

public and key stakeholders, and increase public and key stakeholders, and increase

health care providers’ awareness of disparities.health care providers’ awareness of disparities.

Recommendations:Recommendations:Legal, Regulatory, And PolicyLegal, Regulatory, And Policy

• Avoid fragmentation of health plans along socioeconomic Avoid fragmentation of health plans along socioeconomic lineslines

• Strengthen the stability of patient-provider relationships in Strengthen the stability of patient-provider relationships in publicly funded health planspublicly funded health plans

• Increase U.S. racial and ethnic minorities among health Increase U.S. racial and ethnic minorities among health professionalsprofessionals

• Apply the same managed care protections to publicly Apply the same managed care protections to publicly funded HMO enrollees that apply to private HMO enrolleesfunded HMO enrollees that apply to private HMO enrollees

• Provide greater resources to the U.S. DHHS Office of Civil Provide greater resources to the U.S. DHHS Office of Civil Rights to enforce civil rights lawsRights to enforce civil rights laws

Recommendations: Health Care SystemRecommendations: Health Care System

• Promote the consistency and equity of care through the Promote the consistency and equity of care through the use of evidence-based guidelines;use of evidence-based guidelines;

• Structure payment systems to ensure an adequate Structure payment systems to ensure an adequate

supply of services to minority patients, and limit supply of services to minority patients, and limit provider incentives that may promote disparities;provider incentives that may promote disparities;

• Provide incentives for practices that barriers and Provide incentives for practices that barriers and encourage evidence-based practice;encourage evidence-based practice;

• Promote the use of interpretation services where Promote the use of interpretation services where

community need exists. community need exists.

Recommendations: EducationRecommendations: Education

• Patient education programs Patient education programs – To increase patients’ knowledge of how to best To increase patients’ knowledge of how to best

access care access care – To participate in treatment decisions.To participate in treatment decisions.

• Integrate cross-cultural education into the Integrate cross-cultural education into the training of all current and future health training of all current and future health professionals.professionals.

Recommendations:Recommendations:Data Collection And MonitoringData Collection And Monitoring

• Collect and report data on health care access and Collect and report data on health care access and utilization by patients’utilization by patients’– race race – ethnicityethnicity– socioeconomic statussocioeconomic status– where possible, primary languagewhere possible, primary language

• Include measures of racial and ethnic disparities in Include measures of racial and ethnic disparities in

performance measurement;performance measurement; • Monitor progress toward the elimination of health care Monitor progress toward the elimination of health care

disparities;disparities;

Recommendations: Research Recommendations: Research

• Conduct further research toConduct further research to– identify sources of racial and ethnic identify sources of racial and ethnic

disparities disparities – assess promising intervention strategiesassess promising intervention strategies

• Conduct research on barriers to eliminating Conduct research on barriers to eliminating

disparities.disparities.

Actions Must Actions Must

be Sustained and be Sustained and ComprehensiveComprehensive

Risa Lavizzo-Mourey. Looking Into the Melting Pot Nearly one in every ten U.S. residents were born...

Documents

Transcript of Risa Lavizzo-Mourey. Looking Into the Melting Pot Nearly one in every ten U.S. residents were born...