Racial differences in the treatment of early-stage lung cancer

Sociodemographic differences in the receipt of colorectal cancer surveillance care following treatment with curative intent

BACKGROUND

Despite limited evidence of its effectiveness, most guidelines recommend colorectal cancer survivors undergo posttreatment surveillance care. This article describes the posttreatment use of colon examinations, carcinoembryonic antigen (CEA) testing, and metastatic disease testing among a managed care population.

METHODS

Two hundred fifty-one patients with colorectal cancer enrolled in a managed care organization at diagnosis (1/1/90-12/31/95) and treated with curative intent. Patients were identified via a Cancer Registry maintained by a large group practice. Cumulative incidences of service receipt were estimated using actuarial (Kaplan-Meier) survival analyses. Co- Proportional Hazard Models were used to evaluate the relation of patient sociodemographic and clinical characteristics to service receipt. Average 8-year medical care expenditures were calculated.

RESULTS

Within 18 months of treatment, 55% of the cohort received a colon examination, 71% received CEA testing, and 59% received metastatic disease testing. Whites were more likely than minorities to receive CEA testing (RR = 1.47, P = 0.04) and tended to be more likely to receive a colon examination (RR = 1.43, P = 0.09). As the median household income of a patient's zip code of residence increased, so too did the likelihood of colon examination and metastatic disease testing receipt (RR = 1.09, P = 0.03 and RR = 1.12, P <0.01, respectively). Average 8-year medical care expenditures among the cohort were $30,247.

CONCLUSIONS

Among a population with financial access to care, differences were found in the receipt of colorectal cancer surveillance care by race and income. Additional investigations are needed to understand why minorities and those residing in low-income areas are less likely to receive surveillance care.

Influence of Hispanic ethnicity on outcome after resection of carcinoma of the head of the pancreas

BACKGROUND

Poor outcomes in Hispanic patients have been reported for tumors at a number of sites. The authors sought to determine whether a similar phenomenon occurs in Hispanics after the resection of solid epithelial tumors of the head of the pancreas.

METHODS

Between 1983-1995, 273 patients with noncystic epithelial carcinoma of the head of the pancreas were evaluated. Resection was accomplished in 104 patients (38%); these patients were the focus of the current retrospective review. Of the patients who underwent resection, 26 (25%) were Hispanic and 78 (75%) were non-Hispanic.

RESULTS

Although Hispanic patients tended to present at a significantly younger age and their serum bilirubin level was significantly higher, no other differences in clinical characteristics were observed. After resection, Hispanic patients had a median survival of only 11.4 months, whereas the non-Hispanic group had a median survival of 21.7 months (P = 0.009). Hispanic ethnicity, as well as age > 74 years and jaundice at the time of presentation also were found to be significant prognostic factors on multivariate analysis. Hispanic patients did not present with more advanced disease and no delays in assessment by a physician or in proceeding to surgery were observed. Furthermore, the rate of resection was the same in Hispanic patients and non-Hispanic patients. Long-term survival after palliative bypass was similarly worse in the Hispanic subgroup.

CONCLUSIONS

Hispanic patients treated at the study center appeared to have a diminished survival after resection of a tumor of the head of the pancreas. No treatment-related factors were identified that could explain this discrepancy in outcome.

Racial differences in the cost of treating men with early-stage prostate cancer

OBJECTIVE

To compare the cost and resource utilization in the evaluation, treatment, and 6-month follow-up of African-American and White men undergoing either external beam radiation therapy (XRT) or radical prostatectomy (RP) for early-stage prostate cancer.

DESIGN

Retrospective analysis of cost and resource utilization data from encrypted patient-specific hospital inpatient, hospital outpatient, and physician/supplier data files.

SETTING

National Medicare claims data from 1993 through 1996.

PARTICIPANTS

A random 5% national sample of Medicare beneficiaries from the Health Care Financing Administration Public Use Files for 1993 through 1996.

MEASUREMENTS

Inpatient, outpatient, and physician/supplier Medicare costs.

RESULTS

African-American men undergoing RP for early-stage prostate cancer had significantly higher costs ($21,878 vs $18,786, P < .0001) than did White men. Most of the difference occurred in the inpatient setting. African-American men undergoing XRT had significantly greater costs ($18,131 vs $15,734, P < .0001) than did White men. Most of this difference was generated by longer duration of XRT treatments.

CONCLUSIONS

In early-stage prostate cancer, charges for RP and XRT in African-American men are higher when compared with those for White men.

Racial and ethnic differences in health care access and health outcomes for adults with type 2 diabetes

OBJECTIVE

To evaluate health care access and utilization and health status and outcomes for type 2 diabetic patients according to race and ethnicity and to determine whether health status is influenced by health care access and utilization.

RESEARCH DESIGN AND METHODS

National samples of Caucasians, African-Americans, and Mexican-Americans were studied in the third National Health and Nutrition Examination Survey. Information on medical history and treatment of diabetes, health care access and utilization, and health status and outcomes was obtained by structured questionnaires and by clinical and laboratory assessments.

RESULTS

Almost all patients in each race and ethnic group had one primary source of ambulatory medical care (92-97%), saw one physician at this source (83-92%), and had at least semiannual physician visits (83-90%). Almost all patients > or = 65 years of age had health insurance (99-100%), and for those patients < 65 years of age, Caucasians (91%) and African-Americans (89%) had higher rates of coverage than Mexican-Americans (66%). Rates of treatment with insulin or oral agents (71-78%), eye examination in the previous year (61-70%), blood pressure check in the previous 6 months (83-89%), and the proportion of hypertension that was diagnosed (84-91%) were similar for each race and ethnic group. Lower proportions of African-Americans and Mexican-Americans self-monitored their blood glucose (insulin-treated, 27 vs. 44% of Caucasians), had their cholesterol checked (62-68 vs. 81%), and had their dyslipidemia diagnosed (45 vs. 58%). African-American and Mexican-American patients had a somewhat higher proportion than Caucasian patients, with HbA1c > or = 7% (58-66 vs. 55%), blood pressure > or = 140/90 mmHg among those with diagnosed hypertension (60-65 vs. 55%), and clinical proteinuria (11-14 vs. 5%). In contrast, they had better levels of total cholesterol (> or = 240 mg/dl) (28 -30 vs. 34%) and HDL cholesterol (> or = 45 mg/dl) (46 -59 vs. 38%), and African-American and Mexican-American men were less overweight than Caucasian men (BMI > or = 30) (34-37 vs. 44%), although the opposite was true for women. LDL cholesterol levels and the proportion of patients who smoked cigarettes or were hospitalized in the past year were similar among all three groups. In logistic regression analysis, there was little evidence that levels of blood glucose, blood pressure, lipids, or albuminuria were associated with access to or utilization of health care or with socioeconomic status.

CONCLUSIONS

There are some differences by race and ethnicity in health care access and utilization and in health status and outcomes for adults with type 2 diabetes. However, the magnitude of these differences pale in comparison with the suboptimal health status of all three race and ethnic groups relative to established treatment goals. Health status does not appear to be influenced by access to health care.

Race, ethnicity, and the health care system: public perceptions and experiences

To assess the public's perceptions and attitudes about racial and ethnic differences in health care, the Kaiser Family Foundation surveyed a nationally representative sample of 3,884 whites, African Americans, and Latinos in 1999. The survey found that the majority of Americans are uninformed about health care disparities--many were unaware that blacks fare worse than whites on measures such as infant mortality and life expectancy, and that Latinos are less likely than whites to have health insurance. Views on whether the health system treats people equally were strikingly different by race. For example, most minority Americans perceive that they get lower quality care than whites, but most whites think otherwise. Nonetheless, more minority Americans were concerned about the cost of care than racial barriers. Efforts to eliminate disparities will need to improve public awareness of the problems as well as address racial and financial barriers to care.

African-American women have higher initial HbA1c levels in diabetic pregnancy

OBJECTIVE

African-American women with diabetes are at greater risk for poor glycemic control outside of pregnancy. We evaluated the effect of race on glycemic control in a racially mixed population of women with diabetes entering prenatal care.

RESEARCH DESIGN AND METHODS

HbA1c levels along with demographic data were collected at the first prenatal visit from a group of 234 women with preexisting diabetes. We applied logistic multivariate analysis to identify factors associated with HbA1c levels above the median for the group.

RESULTS

The median HbA1c level for the group was 8%. HbA1c levels were 8.7 +/- 2.0% in African-Americans and 7.7 +/- 1.5% in Caucasians (P < 0.001). African-American racial designation was significantly and independently associated with high HbA1c when controlled for maternal age, parity, White classification, diabetes type, education, marital status, obesity, insurance type, and first trimester entry into care. The effect of race was confined to the nonobese patients, for whom the adjusted odds ratio for African-American race as a predictor of high HbA1c was 8.15 with a 95% CI of 2.41-27.58 (P = 0.001).

CONCLUSIONS

We found a clear racial disparity in glycemic control among women entering prenatal care with preexisting diabetes. This study demonstrates that there generally is need for better glycemic control among reproductive-age women with diabetes, but especially among those who are African-American.

Diversity in emergency medicine--a model program

Emergency medicine's (EM's) development as a specialty has spanned the last 25 years, with the first certifying examination administered by the American Board of Emergency Medicine in 1980. National census data project that the new millennium will bring a U.S. population that will be 40% minority. In the year 2000, the U.S. population had a projected minority population of 28%. The diversity of the patients we treat demonstrates the need for EM programs to diversify their faculty and residency staff. Strategies include expanding recruitment and supporting retention of underrepresented students, faculty, and trainees, addressing barriers that may exist for promotion of underrepresented women and minorities, mentoring underrepresented minority (URM) faculty in research and education, providing opportunities for URMs to advance in the field, and mentoring URMs at the junior high and high school levels in the sciences to expand the applicant pool in the field. The authors describe an academic EM program that is a model program for diversity within our specialty.

African American women and breast cancer: notes from a study of narrative

Survival after breast cancer and after all cancers is significantly worse for African American women than for others. Although many reasons have been proposed, no studies have explored the reception of messages about breast cancer by African American survivors of this disease, and how public images and discourses about breast cancer affects both their perceived risk for this disease and their experiences of illness. Narrative accounts of their lived experiences with breast cancer were collected from 23 African American survivors of breast cancer. Three themes have emerged: (a) Breast cancer is perceived to be a white woman's disease; (b) cancer is caused by experiences of repeated traumatic heartbreak; and finally, (c) there is a perceived lack of social support and understanding for the unique life experiences of the African American survivor of breast cancer. Nurses are on the front line of patient care. In the context of the managed care environment, they spend more time with patients than other health care providers and are soundboards for many patient concerns. As such, they can use the information provided in this study to inform high-risk women, current patients, partners, and other individuals in the medical community of how African American women might inaccurately access their personal risks for breast cancer, despite the public emphasis on this disease. Through the use of culturally sensitive pamphlets, nurses and other medical practitioners can also open discussions with underserved and minority patients as a means of realistically addressing some of these women's fears about breast cancer. These fears are barriers to effective cancer prevention because these individuals may consciously or unconsciously link a diagnosis of breast cancer, or even behaviors related to cancer prevention, to a potential death sentence.

Communication in intensive care settings: the challenge of futility disputes

In intensive care settings, suboptimal communication can erode family trust and fuel so-called "futility" disputes. Presenting a teaching case used by >225 hospitals participating in the Decisions Near the End-of-Life program, we identify critical communication challenges and opportunities. We emphasize that good communication requires not only clear and sensitive language but also clinician self-awareness, psychological insight, and an institutional culture that promotes good communication with families. The article concludes with two examples of steps institutions can take to foster good communication between families and healthcare professionals.

Race, ethnicity, and pain treatment: striving to understand the causes and solutions to the disparities in pain treatment

Pain in the United States is widely recognized to be undertreated; however, the capacity to treat pain has never been greater. The causes of this undertreatment are varied. As we focus on pain and why it is too often ineffectively treated, we also discover that this undertreatment afflicts some more than others. What divides the some from the others isn't limited to one factor, but one particularly disturbing factor is race and ethnicity. Racial and ethnic minority populations are at higher risk for oligoanalgesia, or the ineffective treatment of pain. Only through further study of the differences in pain treatment based on race and ethnicity can we develop strategies to reduce the disparities in care.

Exploring quality of care for African Americans

The continuous health disparities for African Americans when compared with Caucasians raise the question of whether health care objectives designed for African Americans actually address their needs and wants. To explore quality-of-care dimensions from the African American perspective, a combined focus group and modified Delphi approach were used. Three quality-of-care dimensions (patient, provider, and setting roles) were deduced from the data. Qualitative thematic narratives were abstracted. Because African Americans emphasized processes of care, their health outcomes may improve if process factors are judged as important as those of input and outcome in an adapted quality-of-care framework.

Socioeconomic inequalities in cancer survival in England and Wales

BACKGROUND

Cancer survival often has been reported as lower for the poor than the rich, but, to the authors' knowledge, systematic national estimates of deprivation gradients in survival over long periods of time have not been available.

METHODS

The authors estimated national population-based survival rates for almost 3 million people who were diagnosed with 1 of 58 types of cancers (47 in adults, 11 in children) in England and Wales during the 20-year period 1971-1990 and followed through December 31, 1995. Cancer patients were assigned by their address at diagnosis to 1 of 5 categories (quintiles of the national distribution) of material deprivation by using a standard index derived from census data on unemployment, car ownership, household overcrowding, and social class that was available for all 109,000 census tracts in Great Britain. The authors used relative survival rates: the ratio of observed survival among the cancer patients to the survival that would have been expected if they had had the same background mortality as the general population. Background mortality differed widely among socioeconomic categories, and the authors constructed life tables from raw national mortality data by gender, single year of age, calendar period of death, and socioeconomic category to adjust for it. The authors used variance-weighted least squares regression to estimate both time trends in age standardized survival and socioeconomic gradients in survival. The number of avoidable deaths was estimated from the observed mortality excess compared with the expected mortality in each group of patients.

RESULTS

Survival rose steadily for most cancers over 25 years to 1995 in England and Wales, but inequalities in survival between patients living in rich and poor areas were geographically widespread and persistent over this period of time. These patterns existed for 44 of 47 adult cancers examined but not for 11 childhood cancers. These inequalities in survival represented more than 2500 deaths that would have been avoided each year if all cancer patients had had the same chance of surviving up to 5 years after diagnosis as patients in the most affluent group.

CONCLUSIONS

The largest national cancer survival study has provided strong evidence of systematic disadvantage in outcome among patients who lived in poorer districts compared with those who lived in wealthier districts.

Disparities in cancer diagnosis and survival

BACKGROUND

Concern has been raised over the disproportionate cancer mortality among minority and low-income persons. The current study examined differences in disease stage at the time of diagnosis and subsequent survival for patients who are medically indigent compared with the rest of the population of cancer patients in Michigan.

METHODS

The authors linked three Michigan statewide data bases: the Cancer Registry, Medicaid enrollment files, and death certificates. The analysis focused on female breast, cervix, lung, prostate, and colon carcinoma, and differences were analyzed in the incidence, disease stage at the time of diagnosis, and survival between younger women and older women who were either insured or not insured by Medicaid. To estimate the risk of late stage diagnosis and death, the authors used logistic regression, controlling for age, race, and Medicaid enrollment. Ordered logit models also were used as a refinement of disease stage prediction.

RESULTS

Medically indigent persons had a disproportionately larger share of cancer. Persons age < 65 years who were insured by Medicaid had the greatest risk of late stage diagnosis and death across all five disease sites analyzed. African-American women had a greater risk of death from breast carcinoma compared with other women independent of Medicaid status. No interaction effects were found between age, race, and/or gender and Medicaid enrollment.

CONCLUSIONS

The results of this study showed that the disparities in cancer outcomes may be greater than previously thought and are consistent across disease sites. If advancements made in cancer control are to be shared by the low-income population, then improvements clearly are needed in cancer prevention, early detection, and treatment for the poor.

The impact of racism on the delivery of health care and mental health services

This article presents research findings useful in formulating a Best Practices Model for the delivery of mental health services to underserved minority populations. Aspects of the role of racism in health care delivery and public health planning are explored. An argument is made for inclusion of the legacy of the slavery experience and the history of racism in America in understanding the current health care crisis in the African-American population. The development of an outline in APA DSM IV for the use of cultural formulations in psychiatric diagnosis is discussed.

The impact of interferon plus ribavirin on response to therapy in black patients with chronic hepatitis C. The International Hepatitis Interventional Therapy Group

BACKGROUND & AIMS

Black patients with chronic hepatitis C have lower response rates than white patients to interferon monotherapy. The factors responsible for these differences are unknown, as is the impact of combination antiviral therapy on responsiveness among ethnic groups. We evaluated the impact of race on response to therapy in these patients.

METHODS

A total of 1744 patients with chronic hepatitis C were randomized in 2 recent clinical trials to receive 24 or 48 weeks of interferon monotherapy or interferon-ribavirin combination therapy.

RESULTS

Sustained virologic responses occurred in 27% of 1600 whites, 11% of 53 blacks (P = 0.01 vs. white), 44% of 32 Asians, and 16% of 27 Hispanics. No black patient had a sustained virologic response to interferon monotherapy, but 20% and 23% had sustained responses to 24 and 48 weeks, respectively, of combination therapy. Among black patients, 96% had hepatitis C genotype 1 compared with 65% of white subjects (P < 0.0001). Sustained response rates were similar for black and white patients with genotype 1 infection (23% vs. 22%, respectively). Compared with whites, black patients were older, weighed more, and had higher median Histologic Activity Index scores but did not differ in sex, baseline alanine aminotransferase or hepatitis C virus (HCV)-RNA levels, degree of fibrosis or percentage with cirrhosis, or other demographic variables. White subjects had a significantly greater reduction in HCV-RNA levels than blacks at weeks 4, 12, 24, and 48 of therapy, but only for black patients treated with interferon monotherapy. The decreased reduction of HCV-RNA reduction among blacks was eliminated by combination therapy.

CONCLUSIONS

These observations suggest that the impaired responsiveness of black patients to interferon monotherapy can be overcome partially by combination interferon-ribavirin therapy.

Facility effects on racial differences in nursing home quality of care

This paper reviews the literature on racial/ethnic differences in nursing home quality, segregated access to nursing home care, and organizational and community factors that may influence access and quality of care. We present illustrative data on county demographics and the racial mix of African American residents in nursing homes in these counties for a sample of four states. We also briefly describe plans for multilevel modeling to test variation in racial/ethnic disparities in care as a function of nursing home structures and processes and community context.

Community, service, and policy strategies to improve health care access in the changing urban environment

Urban communities continue to face formidable historic challenges to improving public health. However, reinvestment initiatives, changing demographics, and growth in urban areas are creating changes that offer new opportunities for improving health while requiring that health systems be adapted to residents' health needs. This commentary suggests that health care improvement in metropolitan areas will require setting local, state, and national agendas around 3 priorities. First, health care must reorient around powerful population dynamics, in particular, cultural diversity, growing numbers of elderly, those in welfare-workplace transition, and those unable to negotiate an increasingly complex health system. Second, communities and governments must assess the consequences of health professional shortages, safety net provider closures and conversions, and new marketplace pressures in terms of their effects on access to care for vulnerable urban populations; they must also weigh the potential value of emerging models for improving those populations' care. Finally, governments at all levels should use their influence through accreditation, standards, tobacco settlements, and other financing streams to educate and guide urban providers in directions that respond to urban communities' health care needs.

The effects of patient sex and race on medical students' ratings of quality of life

PURPOSE

Although previous studies have examined race and sex differences in health care, few studies have investigated the possible role of physician bias. We evaluated the influence of race and sex on medical students' perceptions of patients' symptoms to determine if there are differences in these perceptions early in medical training.

SUBJECTS AND METHODS

One-hundred sixty-four medical students were randomly assigned to view a video of a black female or white male actor portraying patients with identical symptoms of angina. We evaluated students' perceptions of the actors' health state (based on their assessment of quality of life) using a visual analog scale and a standard rating technique, as well as the type of chest pain diagnosis.

RESULTS

Students assigned a lower value (indicating a less desirable health state) to the black woman than to the white man with identical symptoms [visual scale (mean +/- SD): 72 +/- 13 vs 67 +/- 12, P <0.02; standard gamble: 87 +/- 10 vs 80 +/- 15, P < 0.001). Nonminority students reported higher mean values for the white male patient (standard gamble: 89 +/- 8 vs 81 +/- 14 for the black female patient), whereas minority students' assessments did not differ by patient. Male students assigned a slightly lower value to the black female patient (standard gamble: 76 +/- 16 vs 87 +/- 10 for the white male patient). Students were less likely to characterize the black female patient's symptoms as angina (46% vs 74% for the white male patient, P = 0.001).

CONCLUSIONS

The way that medical students perceive patient symptoms appears to be affected by nonmedical factors.

Maternal mortality, United States and Canada, 1982-1997

BACKGROUND

The 1998 public awareness campaign on Safe Motherhood called attention to the issue of maternal mortality worldwide. This paper focuses upon maternal mortality trends in the United States and Canada, and examines differentials in maternal mortality in the United States by maternal characteristics.

METHODS

Data from the vital statistics systems of the United States and Canada were used in the analysis. Both systems identify maternal deaths using the definition of the World Health Organization's International Classification of Diseases. Numbers of deaths, maternal mortality rates, and confidence intervals for the rates are shown in the paper.

RESULTS

Maternal mortality declined for much of the century in both countries, but the rates have not changed substantially between 1982 and 1997. In this period the maternal mortality levels were lower in Canada than in the United States. Maternal mortality rates vary by maternal characteristics, especially maternal age and race.

CONCLUSIONS

Maternal mortality continues to be an issue in developed countries, such as the United States and Canada. Maternal mortality rates have been stable recently, despite evidence that many maternal deaths continue to be preventable. Additional investment is needed to realize further improvements in maternal mortality.

Racial differences in the survival of childhood B-precursor acute lymphoblastic leukemia: a Pediatric Oncology Group Study

PURPOSE

We conducted a historic cohort study to test the hypothesis that, after adjustment for biologic factors, African-American (AA) children and Spanish surname (SS) children with newly diagnosed B-precursor acute lymphoblastic leukemia had lower survival than did comparable white children.

PATIENTS AND METHODS

From 1981 to 1994, 4,061 white, 518 AA, and 507 SS children aged 1 to 20 years were treated on three successive Pediatric Oncology Group multicenter randomized clinical trials.

RESULTS

AA and SS patients were more likely to have adverse prognostic features at diagnosis and lower survival than were white patients. The 5-year cumulative survival rates were (probability +/- SE) 81.9% +/- 0.6%, 68.6% +/- 2.1%, and 74.9% +/- 2.0% for white, AA, and SS children, respectively. Adjusting for age, leukocyte count, sex, era of treatment, and leukemia blast cell ploidy, we found that AA children had a 42% excess mortality rate compared with white children (proportional hazards ratio [PHR] = 1.42; 95% confidence interval [CI], 1.12 to 1. 80), and SS children had a 33% excess mortality rate compared with white children (PHR = 1.33; 95% CI, 1.19 to 1.49).

CONCLUSION

Clinical presentation, tumor biology, and deviations from prescribed therapy did not explain the differences in survival and event-free survival that we observed, although differences seem to be diminishing over time with improvements in therapy. The disparity in outcome for AA and SS children is most likely related to variations in chemotherapeutic response to therapy and not to compliance. Further improvements in outcome may require individualized dosing based on specific pharmacogenetic profiles, especially for AA and SS children.

Part I. "Behind every problem lies an opportunity": meeting the challenge of diversity in medical schools

The authors describe the historical evolution and present status of affirmative action in medical school admission policies. The demographic transformation of the medical student body between 1965 and 1998 from a homogeneous white and male group to one that includes a significant number of women and minority students is presented. Challenges to affirmative action are outlined. In addition, the authors note the increasing diversity of the general population and discuss the benefits of diversity to medical practice, research, and education. However, the upper ranks of professors and administrators remain white and male. The rationale for an innovative course on the history of bias in medicine and the benefits that diversity brings to the medical enterprise are presented.