Racial Disparities in Our Health Care System

Dear Colleague,

New England Journal of Medicine

When the Institute of Medicine (IOM) published its report entitled ?Unequal Treatment? in 2002,¹ the issue of racial and ethnic disparities in health care exploded onto the public stage. Although mountains of evidence had been accumulating in the medical literature and in the lay press for decades regarding this issue, that report forced all the key players in American health care, including government agencies, health insurance plans, hospitals, as well as physicians, to take a step back and reexamine their own practices. Subsequently, many national organizations, including the American Medical Association (AMA), initiated large-scale campaigns to combat the root causes of discrimination within our health care system. Three years later, just as the initial call to action stirred up by the IOM report begins to fade, a new series of articles published in August 2005 in the has reinforced our previous knowledge about the extent of racial and ethnic disparities while also offering a glimmer of hope as we continue to move forward.

In its 2002 report, the IOM defines racial and ethnic disparities as ?racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention.?¹ Indeed, it found that African American patients in America, and in some cases Hispanic patients, are less likely to receive appropriate cardiac medication and interventions, cancer diagnostic tests, kidney transplantation, antiretroviral drugs for HIV infection, diabetes care, pediatric care, mental health care, and a host of other health benefits even after controlling for insurance status, income, age, comorbid conditions, and differences in symptom expression. The IOM found the causes of these disparities to be equally broad and complex, and divided them into health system factors and patient-provider factors.

Health system factors include language and cultural barriers, the tendency for racial minorities to have lower-end health plans, and the lack of community resources, such as adequately stocked pharmacies, in minority neighborhoods. Patient-provider factors include provider bias against minority patients, greater clinical uncertainty when treating minority patients, stereotypes about minority health behaviors and compliance, and mistrust and refusal of care by minority patients themselves who have had previous negative experiences with the health care system.

New England Journal of Medicine

The recently published series of studies in the has rekindled public debate on the issue of racial disparities in health care. In one study of nearly 600,000 patients who had myocardial infarction (MI) between 1994 and 2002, African American men and women in the United States were less likely to receive reperfusion therapy and coronary angiography compared with white men and women, and the racial gap in cardiac care remained unchanged over the 8-year study period.² Another study examining the use of high-cost surgical procedures found that for 5 of the 9 procedures studied, the racial gap increased during the 1990s and remained statistically unchanged for the remainder of the procedures.³ In contrast, a study looking at quality of care indicators for Medicare managed care plans offers some good news.⁴ Since 1997, Medicare managed care plans have been required to report to the government on a series of quality-of-care indicators, ranging from mammogram screenings for breast cancer to testing of low-density lipoprotein cholesterol in diabetic and post-MI patients. The investigators found that since reporting began, the racial differences for 7 of the 9 quality indicators narrowed significantly, in some cases nearly disappearing altogether. This study reinforces previous evidence that systemwide efforts to improve quality of care, whether through mandatory reporting or physician education and incentives, can play an important role in reducing racial disparities in health care.

Since the publication of the IOM report, the AMA has taken a lead role in addressing the issue of racial disparities in health care. In 2002, the AMA?s House of Delegates voted to make elimination of racial and ethnic disparities in health care an issue of high priority. The AMA signed a ?memorandum of understanding? with the US Department of Health and Human Services, committing the 2 bodies to work cooperatively to achieve the goals of Healthy People 2010, including eliminating disparities in health care. The AMA also partnered with the Kaiser Family Foundation and the Robert Wood Johnson Foundation on a campaign to raise physicians? awareness about racial and ethnic disparities in health care. In 2004, in conjunction with the National Medical Association and 37 state and specialty medical organizations, the AMA launched the Commission to End Health Care Disparities. Building off recommendations from the IOM report, the newly created commission has agreed to focus on 4 basic strategies, including increasing public awareness of disparities, promoting better data gathering to aid quality improvements, promoting health care workforce diversity, and increasing provider education and training.

Although we are still many years away from eliminating the scourge of racial and ethnic disparities in health care, the national momentum created by the IOM report and continued by more recent studies makes this the perfect time to advocate for solutions to this complex problem. Residents and fellows, as the first-line care givers for many minority patients, have a huge role to play in overcoming health care disparities, both at the individual and the systemwide level. Whether through local initiatives in your own hospital or community or at the national level via the AMA or other organizations, I encourage you to get involved and help heal the scars of racial and ethnic disparities that continue to mar the face of our health care system.

Adam Levine, MD

Alternate Delegate

American Medical Association

Resident and Fellow Section

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

1. Smedley B, Stith A, Nelson A, eds. . Washington, DC: National Academies Press; 2003. Available at www.nap.edu/books/030908265X/html/.

N Engl J Med.

2. Vaccarino V, Rathore SS, Wenger NK, et al, for the National Registry of Myocardial Infarction Investigators. Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002. 2005;353:671-682.

N Engl J Med

3. Jha AK, Fisher ES, Li Z, et al. Racial trends in the use of major procedures among the elderly. . 2005;353:683-691.

N Engl J Med

4. Trivedi AN, Zaslavsky AM, Schneider EC, et al. Trends in the quality of care and racial disparities in Medicare managed care. . 2005;353:692-700.