Racial and ethnic disparities in health care

Cultural Humility: A Proposed Model for a Continuing Professional Development Program

Continuing professional development (CPD) is an essential component of professional practice for registered health practitioners to maintain and enhance knowledge, skills and abilities. There are many topics that practitioners may pursue relevant to their practice environment, and, in recent years, providing culturally safe and respectful practice is an emerging area of need. Unfortunately, many health professionals, whilst willing to offer cultural safe healthcare, may be uncertain of how to enact that practice. The World Health Organisation recognises attainment of the highest possible standard of health as a basic human right, and cultural safety is increasingly becoming an expectation of health professionals. To address this need and the insufficiency of support in the literature, the authors have presented a discussion paper on various aspects of cultural safety and the underlying constructs, such as cultures, that support it. The discussion takes into account core constructs that signpost the path to cultural safety and recognises the role and accountability of all levels of the healthcare system, not merely the practitioner. Finally, we propose a model program for a cultural humility CPD activity incorporating pre-work, online modules, interactive workshop, reflection on professional practice and a post-workshop evaluation.

The willingness and actual situation of Chinese cancer patients and their family members participating in medical decision-making

OBJECTIVE

In China, not only patients and physicians are involved in medical decision-making (MDM) but also the patients' family members. The objective is to investigate the willingness and actual situation of cancer patients and their family members participating in the MDM process.

METHODS

In this cross-sectional study, questionnaires were administered to 247 pairs of cancer inpatients and their relatives. Information regarding participants' willingness and actual experience during the decision-making process was documented. Eligible participants were cancer inpatients or their relatives, 18 years of age or older, and informed of the cancer diagnosis. All the patients should have received chemotherapy.

RESULTS

The effective response rate was 72.9% (180/247). Over half of the patients (53.3%) and family members (57.8%) were willing to be part of the MDM process. In contrast, only 35.0% of patients and 46.1% of family members actually experienced this process (p = 0.001 and p = 0.011, respectively). Fewer family members (42.2%) than patients (53.3%) believed that patients should be involved in the MDM process (p < 0.001). Patients who were the head of their family (odds ratio 2.577, 95% CI 1.198-5.556, p = 0.015) experienced more involvement in MDM.

CONCLUSIONS

Although more than half of Chinese cancer patients and family members wanted to be part of MDM, the actual participation was below their expectation. Majority of family members do not want the patients to be involved in the process of MDM.

Does decisional conflict differ across race and ethnicity groups? A study of parents whose children have a life-threatening illness

OBJECTIVE

Children with life-threatening illnesses and their families may face a myriad of medical decisions in their lifetimes. Oftentimes these complicated medical decisions cause disagreements among patients, families, and providers about what is the best course of action. Although no evidence exists, it is possible that conflict may affect subgroups of the population differently. This study aims to investigate how decisional conflict varies among racial and ethnic subgroups.

SAMPLE

Two hundred sixty-six surveys were completed with parents whose children have a life-threatening illness. All children lived in Florida and were enrolled in the Medicaid program. The Decisional Conflict Scale, overall and broken down into its five distinct subscales, was used to assess parental decision-making. Descriptive, bivariate, and multivariate analyses were conducted. Subgroup analyses were conducted on Latino respondents.

RESULTS

Our bivariate results suggest that minority parents report less Effective Decision Making (p<0.05) and report less Support in Decision Making (p<0.05) compared to white, non-Hispanic parents. For the subgroup analysis, we found that those who identify as Mexican American and Central/South American report having greater Uncertainty in Choosing Options (p<0.05) and less Values Clarity (p<0.05) as compared to Puerto Rican or Cuban Americans. Results from the multivariate analyses suggest that those whose primary language is not English are associated with greater Uncertainty in Choosing Options (p<0.05). Values Clarity was lower for children who were diagnosed with their life-threatening condition at birth (p<0.05) as compared to children diagnosed at a later time.

CONCLUSIONS

Our study is the first to describe racial and ethnic differences in decisional conflict of parents of children with life-threatening illnesses. Significant differences exist by race, ethnicity, language spoken, and diagnosis time across several subdomains of decisional conflict. These differences are important to address when creating clinical care plans, engaging in shared decision-making, and creating interventions to alleviate decisional conflict.

Practitioner and client explanations for disparities in health care use between migrant and non-migrant groups in Sweden: a qualitative study

To investigate variations in explanations given for disparities in health care use between migrant and non-migrant groups, by clients and care providers in Sweden. Qualitative evidence collected during in-depth interviews with five 'migrant' health service clients and five physicians. The interview data generated three categories which were perceived by respondents to produce ethnic differences in health service use: "Communication issues", "Cultural differences in approaches to medical consultations" and "Effects of perceptions of inequalities in care quality and discrimination". Explanations for disparities in health care use in Sweden can be categorized into those reflecting social/structural conditions and the presence/absence of power and those using cultural/behavioural explanations. The negative perceptions of 'migrant' clients held by some Swedish physicians place the onus for addressing their poor health with the clients themselves and risks perpetuating their health disadvantage. The power disparity between doctors and 'migrant' patients encourages a sense of powerlessness and mistreatment among patients.

More educated emergency department patients are less likely to receive opioids for acute pain

Inadequate treatment of pain in United States emergency departments (EDs) is common, in part because of the limited and idiosyncratic use of opioids by emergency providers. This study sought to determine the relationship between patient socioeconomic characteristics and the likelihood that they would receive opioids during a pain-related ED visit. We conducted a cross-sectional analysis of ED data obtained as part of a multicenter study of outcomes after minor motor vehicle collision (MVC). Study patients were non-Hispanic white patients between the ages of 18 and 65 years who were evaluated and discharged home from 1 of 8 EDs in 4 states. Socioeconomic characteristics include educational attainment and income. Of 690 enrolled patients, the majority had moderate or severe pain (80%). Patients with higher education attainment had lower levels of pain, pain catastrophizing, perceived life threat, and distress. More educated patients were also less likely to receive opioids during their ED visit. Opioids were given to 54% of patients who did not complete high school vs 10% of patients with post-college education (χ(2) test P<.001). Differences in the frequency of opioid administration between patients with the lowest educational attainment (39%, 95% confidence interval 22% to 60%) and highest educational attainment (13%, 95% confidence interval 7% to 23%) remained after adjustment for age, sex, income, and pain severity (P=.01). In this sample of post-MVC ED patients, more educated patients were less likely to receive opioids. Further study is needed to assess the generalizability of these findings and to determine the reason for the difference.

Maternal care and birth outcomes among ethnic minority women in Finland

Background

Care during pregnancy and labour is of great importance in every culture. Studies show that people of migrant origin have barriers to obtaining accessible and good quality care compared to people in the host society. The aim of this study is to compare the access to and use of maternity services, and their outcomes among ethnic minority women having a singleton birth in Finland.

Methods

The study is based on data from the Finnish Medical Birth Register in 1999–2001 linked with the information of Statistics Finland on woman's country of birth, citizenship and mother tongue. Our study data included 6,532 women of foreign origin (3.9% of all singletons) giving singleton birth in Finland during 1999–2001 (compared to 158,469 Finnish origin singletons).

Results

Most women have migrated during the last fifteen years, mainly from Russia, Baltic countries, Somalia and East Europe. Migrant origin women participated substantially in prenatal care. Interventions performed or needed during pregnancy and childbirth varied between ethnic groups. Women of African and Somali origin had most health problems resulted in the highest perinatal mortality rates. Women from East Europe, the Middle East, North Africa and Somalia had a significant risk of low birth weight and small for gestational age newborns. Most premature newborns were found among women from the Middle East, North Africa and South Asia. Primiparous women from Africa, Somalia and Latin America and Caribbean had most caesarean sections while newborns of Latin American origin had more interventions after birth.

Conclusion

Despite good general coverage of maternal care among migrant origin women, there were clear variations in the type of treatment given to them or needed by them. African origin women had the most health problems during pregnancy and childbirth and the worst perinatal outcomes indicating the urgent need of targeted preventive and special care. These study results do not confirm either healthy migrant effect or epidemiological paradox according to which migrant origin women have considerable good birth outcomes.

Facility and county effects on racial differences in nursing home quality indicators

This study's goal was to examine the effects of nursing home (NH) and county racial mix on quality of care in NHs. We examined quality indicator (QI) outcomes for residents in 408 urban New York NHs in July through September, 1995. The QI outcomes studied were restraint and antipsychotic drug use (for low and high-risk residents), and at study commencement, these QIs were being used by the Centers for Medicare and Medicaid Services to monitor the quality of care in USA Medicare and/or Medicaid-certified NHs. A hierarchical modeling approach was used to properly reflect the nesting of both residents within NHs and NHs within counties. Separate regression models were fit to the two strata of interest (Urban Non-Hispanic Whites and Urban African Americans) to test, for each race group, the effect on quality of residing in NHs and counties with higher proportions of African Americans (than state medians). Descriptive analyses found that, compared to Whites, the unadjusted restraint rate was lower for African Americans while the antipsychotic drug rate was higher. For both race groups, multi-level analyses showed residence in for-profit NHs was associated with higher likelihoods of being restrained, and of receiving antipsychotic drugs. Also, for both race groups, residence in NHs with higher proportions of African-Americans was associated with lower likelihoods of being restrained and with higher, statistically nonsignificant, likelihoods of receiving antipsychotic drugs. Higher NH nurse staffing ratios were associated with higher likelihoods of being restrained and with lower likelihoods of antipsychotic drug use (statistically significant for low-risk African-Americans). Findings support the notion that differential care is provided in USA NHs caring for higher proportions of African-American residents and thereby suggest intervention at the organizational level is warranted to improve QI outcomes for both race groups.

Physicians' perceptions of patients' social and behavioral characteristics and race disparities in treatment recommendations for men with coronary artery disease

OBJECTIVES

A growing body of evidence suggests that provider decisionmaking contributes to racial/ethnic disparities in care. We examined the factors mediating the relationship between patient race/ethnicity and provider recommendations for coronary artery bypass graft surgery.

METHODS

Analyses were conducted with a data set that included medical record, angiogram, and provider survey data on postangiogram encounters with patients who were categorized as appropriate candidates for coronary artery bypass graft surgery.

RESULTS

Race significantly influenced physician recommendations among male, but not female, patients. Physicians' perceptions of patients' education and physical activity preferences were significant predictors of their recommendations, independent of clinical factors, appropriateness, payer, and physician characteristics. Furthermore, these variables mediated the effects of patient race on provider recommendations.

CONCLUSIONS

Our findings point to the importance of research and intervention strategies addressing the ways in which providers' beliefs about patients mediate disparities in treatment. In addition, they highlight the need for discourse and consensus development on the role of social factors in clinical decisionmaking.

Racial differences in reperfusion therapy use in patients hospitalized with myocardial infarction: a regional phenomenon

BACKGROUND

Racial differences in reperfusion therapy use among patients hospitalized with myocardial infarction (MI) have been previously reported as national phenomenon. However, it is unclear whether racial differences in treatment vary by region.

METHODS

Using data from the National Registry of Myocardial Infarction-2 and -3, a cohort of patients hospitalized with MI in the United States between 1994 and 2000, we sought to determine whether racial differences in reperfusion therapy use varied by geographic region in patients eligible for reperfusion therapy with no clinical contraindications to treatment (n = 204 230).

RESULTS

Black patients had lower crude rates of reperfusion therapy than white patients (66.5% vs 69.9%, -3.3% racial difference, 99% CI -4.4% to -2.2%) overall. However, racial differences in reperfusion therapy use varied by geographic region. Reperfusion therapy rates were similar for black patients and white patients in the Northeast (67.9% black vs 65.3% white, +2.7% racial difference, 99% CI -0.5% to 5.8%) and statistically comparable for patients in the Midwest (68.3% black vs 69.0% white, -0.7% racial difference, 99% CI -2.9% to 1.5%) and West (70.7% black vs 72.6% white, -1.9% racial difference, 99% CI -5.1% to 1.2%). Racial differences in reperfusion therapy use were greatest for patients hospitalized in the South (64.5% black vs 71.7% white, -7.1% racial difference, 99% CI -8.7% to -5.6%). Racial differences were reduced, but geographic variations in racial differences persisted after multivariable adjustment.

CONCLUSIONS

Lower rates of reperfusion therapy use among black patients with MI do not reflect a national pattern of racial differences in treatment, but a practice pattern predominantly attributable to the South.

Not all patients want to participate in decision making. A national study of public preferences

BACKGROUND

The Institute of Medicine calls for physicians to engage patients in making clinical decisions, but not every patient may want the same level of participation.

OBJECTIVES

1) To assess public preferences for participation in decision making in a representative sample of the U.S. population. 2) To understand how demographic variables and health status influence people's preferences for participation in decision making.

DESIGN AND PARTICIPANTS

A population-based survey of a fully representative sample of English-speaking adults was conducted in concert with the 2002 General Social Survey (N= 2,765). Respondents expressed preferences ranging from patient-directed to physician-directed styles on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). Logistic regression was used to assess the relationships of demographic variables and health status to preferences.

MAIN RESULTS

Nearly all respondents (96%) preferred to be offered choices and to be asked their opinions. In contrast, half of the respondents (52%) preferred to leave final decisions to their physicians and 44% preferred to rely on physicians for medical knowledge rather than seeking out information themselves. Women, more educated, and healthier people were more likely to prefer an active role in decision making. African-American and Hispanic respondents were more likely to prefer that physicians make the decisions. Preferences for an active role increased with age up to 45 years, but then declined.

CONCLUSION

This population-based study demonstrates that people vary substantially in their preferences for participation in decision making. Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly.

The association of race and ethnicity with rates of drug and alcohol testing among US trauma patients

BACKGROUND

Racial and ethnic minority patients often receive differential medical care compared to Caucasians. The aim of this study was to evaluate the association of race and ethnicity with rates of alcohol and drug testing among adult US trauma patients.

METHODS

Data for 79,246 adults admitted to 58 institutions participating in the US National Trauma Data Bank were evaluated using multivariable, hierarchical, mixed-effects analyses to determine the odds of receiving alcohol and drug testing among different racial/ethnic groups. The primary outcome variable was whether an alcohol or drug test was performed. The secondary outcome variable was the results of those tests. Participants were stratified by injury severity using the Injury Severity Score. Additional case-mix variables included: gender, age, Glasgow Coma Scale, day and time of arrival, and payment source.

RESULTS

Black and Hispanic males in all injury severity groups were tested for alcohol more frequently than Caucasian males (odds ratio for Black men 1.31, 95% confidence interval 1.16-1.47; and for Hispanic men 1.45, 95% confidence interval 1.19-1.77, in the moderate injury group). Hispanic males in the moderate injury group were also tested for drugs more frequently then Caucasian males (odds ratio 1.33, 95% confidence interval 1.09-1.63).

CONCLUSION

Racial and ethnic minority trauma patients in the US are tested for alcohol and drugs at higher rates after adjusting for potential confounders. Because having a positive alcohol or drug test can adversely affect a patient's medical care, differential testing that is racially or ethnically biased may place minority patients at risk of receiving disparate care.

Distributional issues in the analysis of preventable hospitalizations

OBJECTIVE

To describe patterns in ambulatory care sensitive (ACS) admissions at the zip code level based on zip code demographic and other characteristics. These patterns include trends over time, persistence within zip codes over time, and variation between and within socioeconomic strata.

DATA SOURCES

New York State hospital discharge data 1990-1998, U.S. census data 1990, and New York State birth records 1990.

STUDY DESIGN

Age- and sex-adjusted rates and volumes of ACS admissions are calculated at the zip code level. Descriptive statistics are analyzed cross-sectionally and over time. Kernel density functions are estimated across income strata. Ordinary and quantile regression techniques are used to determine the impact of socioeconomic variables on average and extreme values of the distribution of ACS admission rates.

PRINCIPAL FINDINGS

Ambulatory care sensitive admissions rates declined during the study period but in conjunction with a greater decline in overall admission rates. Thus, as a percentage of total admissions, they actually rose by 4 percent. Ambulatory care sensitive admissions are geographically concentrated and rates are highly persistent within zip codes over time. Even on a log scale ACS admissions are typically greater and exhibit more variability among low-income zip codes. Other variables positively associated with ACS admissions are total population, births to unwed mothers (a proxy for family structure), black population, Hispanic population, and the number of non-ACS admissions. Births to immigrant mothers (a proxy for immigrant population) are negatively associated with ACS admissions.

CONCLUSIONS

The concentration and persistence of ACS admissions point to a chronic, geographically limited deficiency of primary ambulatory care in the most underserved neighborhoods. Much of the difference in preventable hospitalization levels between high- and low-income areas is driven by very high volumes in the low-income areas unrelated to population density. New York data suggest that most costs from preventable hospitalizations could be saved by focusing on targeted neighborhoods. Socioeconomic and area utilization variables play a role in both average and extreme values of the rate of preventable hospitalizations at the zip code level. Since variables that affect the average volume of preventable hospitalizations can change the distribution of that volume, analysis based on averages alone may be inadequate. The findings on area demographics and non-ACS admissions point to the need to better understand social and cultural issues as well as local admitting practice patterns to encourage appropriate and efficient use of the health care delivery system.

Paved with good intentions: do public health and human service providers contribute to racial/ethnic disparities in health?

There is extensive evidence of racial/ethnic disparities in receipt of health care. The potential contribution of provider behavior to such disparities has remained largely unexplored. Do health and human service providers behave in ways that contribute to systematic inequities in care and outcomes? If so, why does this occur? The authors build on existing evidence to provide an integrated, coherent, and sound approach to research on providers' contributions to racial/ethnic disparities. They review the evidence regarding provider contributions to disparities in outcomes and describe a causal model representing an integrated set of hypothesized mechanisms through which health care providers' behaviors may contribute to these disparities.

Research on the provider contribution to race/ethnicity disparities in medical care

OBJECTIVE

Little is known about why black patients and other ethnic/racial minorities are less likely to receive the best treatments independent of clinical appropriateness, payer, and treatment site. Although both provider and patient behavior have been suggested as possible explanatory factors, the potential role of provider behavior has remained largely unexplored. Does provider behavior contribute to systematic inequities? If so, why? The purpose of this paper is to build on existing evidence to provide an integrated, coherent, and sound approach to future research on the provider contribution to race/ethnicity disparities in medical care. First, the existing evidence suggestive of a provider contribution to race/ethnicity variance in medical care is discussed. Second, a proposed causal model, based on a review of the social cognition and provider behavior literature, representing an integrated set of hypothesized mechanisms through which physician behavior may contribute to race/ethnicity disparities in care is presented.

CONCLUSION

There is sufficient evidence for the hypothesis that provider behavior contributes to race/ethnicity disparities in care to warrant further study. Although there is some evidence of support of the hypotheses that both provider beliefs about of patients and provider behavior during encounters are independently influenced by patient race/ethnicity further systematic rigorous study is needed and is proposed as a major immediate research priority. These mechanisms deserve intensive research focus as they may prove to be the most promising targets for interventions intended to ameliorate the provider contribution to disparities in care.