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3 MEASURING DISPARITIES IN HEALTH CARE QUALITY AND SERVICE UTILIZATION Thomas A. LaVeist Over the past century the United States has experienced a large decline in mortality and enjoyed significant gains in life expectancy. Yet, while the U.S. has experienced a sustained pattern of improving health status indicators, disparities in health status among American racial and ethnic minority groups have persisted. Most notably, African Americans consistently have the worst health profile among all major American racial and ethnic groups. As Williams and Rucker (Williams and Rucker, 2000) demonstrate, the overall Afiican American mortality rate was sixty percent higher than that of Whites in 1995. This is precisely what it was in 1950. While the pattern of racial and ethnic disparities in health has been well documented and reported, consensual explanations for racial and ethnic health disparities have been elusive. This is because much of the published research on racial disparities has focused on descriptions rather than on explanations (LaVeist, 20001. In the main, those who have attempted to explain the etiology of health disparities have provided generalized accounts. There is evidence to support environmental (Buliard, 1983; Robinson, 1989), social (Lillie-Blanton et al., 1996; Ren et al., 1999), and behavioral factors (tannin et al., 1998), as well as factors related to socioeconomic status (Williams and Collins, 1995~. However, evidence of the contribution of biogenetic factors is limited and controversial (Bach et al., 2002; Goodman, 2000; Wood, 2001~. Health care is an additional area that has received attention as a possible contributor to health status disparities. A large and growing literature has documented racial and ethnic disparities in access, utilization, and quality of care (Geiger, 2002; Kressin and Peterson, 2001; Mayberry et al., 2000~. Based in 75
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76 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT part on these persistent findings, the U.S. Congress in 1999 mandated that the Agency for Healthcare Research and Quality (AHRQ) produce an annual report on the status of health care disparities, which will be called the National Healthcare Disparities Report (NHDR). AHRQ commissioned the Institute of Medicine (IOM) for guidance in designing the report. This paper comments on various aspects of the NHDR. Specifically, this paper will: Identify major areas in health care services and quality where racial and ethnic disparities exist; Identify major areas in health care services and quality where racial and ethnic disparities are minimal; Identify the kinds of disparities on which the NHDR should focus; and Comment on approaches to reporting health care disparities. 3-1. RACE, ETHNICITY, AND DIFFERENCES IN HEALTH CARE The relationship between patient race or ethnicity and health care services can be placed on a continuum. On one end of the continuum is health care equality, which can be characterized as health care services in which the rates of utilization for racial or ethnic minorities are equal to the rates for comparable White populations. In the middle are health care disparities, or differences in the rates of utilization of health care services where racial or ethnic minorities have substantively Tower rates of utilization. On the other end are what will be called hyperdisparities, which can be characterized as greater rates of minority utilization of services that are often less desirable or a suboptimal pattern of patient service utilization that extends to access to care. Examples include greater rates of medical errors or limb amputations for diabetes patients (IOM, 2002~. Other examples of hyperdisparities are ambulatory care-sensitive hospitalizations (Curler
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3: MEASURING DISPARITIES 77 et al., 1998), missed diagnoses (Pope et al., 2000), and iakogenic injury (Brennan et al., 199 ~a; Brennan et al., ~ 99 Ib). Equalities in Health Care Services and Quality There is a generally acknowledged bias against the publication of studies that yield "nonfindings." As such, the identification of areas without racial and ethnic disparities is more difficult than finding areas where disparities exist. While federal reports are somewhat helpful in identifying health care equalities, federal data sources in health care (as opposed to health status) are less so. Because of this, it is important to note that focusing on the number of identified health care disparities and hyperdisparities relative to the number of equalities may distort one's perception of racial and ethnic differences in health care. However, it is possible to identify several areas of health care equality even though they are more difficult to find. Perez-Stable et al. (Perez-Stable et al., 1995) conducted a telephone survey of Hispanic and White adults, aged 35 to 74 and living in the San Francisco area, to determine their utilization of cancer screening tests. The survey found no differences in the use of fecal occult blood tests, sigmoidoscopy, Pap smears, clinical breast examinations, and screening mammograms. Additionally, Stafford et al. (Stafford et al., 1998) examined utilization of hormone replacement therapy among African American and White patients in the National Ambulatory Medical Care Survey for 1989 and 1996. This analysis found that racial disparities in hormone replacement therapy diminished over time, particularly for women without menopausal symptoms. However, while the disparity has diminished, there are still significant differences. The adjusted odds ratio for hormone replacement in women without menopausal symptoms increased from 0.31 to 0.57, and the adjusted odds ratio among women with menopausal symptoms increased from 0.3 ~ to 0.86. Studies that examine a broad array of health conditions are an additional source of "non-findings." One study examined racial differences in medical or surgical procedures in the Medicare population (Escarce et al., 1993). Of the 32 procedures examined, two (prostatectomy and barium enema) had no significant racial
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78 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT differences. Lee et al. (Lee et al., 1998) also studied Medicare records, but examined only 18 procedures. Eleven of the 18 procedures were not associated with disparities (coronary angioplasty, magnetic resonance imaging (MRI) of the brain, flexible sigmoidoscopy, colonoscopy, barium enema, total hip replacement, hip repair, mammogram, mastectomy, and radiation therapy). Bennett et al. (Bennett et al., 1995) found no significant differences among African American, Hispanic, and White patients in the Veterans Administration (VA) for in-hospital mortality rates, timing of a bronchoscopy, and receipt of timely anti-pneumoniacystis carinii pneumonia (PCP) medications among HTV/AIDS patients. Findings such as these in the VA system suggest an interesting paradox. Studies of the health care system used by active military personnel have found no racial and ethnic disparities in care (Dominitz et al., 1998; Taylor et al., 1997~. However, some studies of the VA system, which is used by former military personnel, have documented racial disparities (Peterson et al., 1994; Whittle et al., 1993~. One plausible explanation for this is that the active duty health care system, including health care providers and patients, is part of a broad military culture tightly controlled by a chain of command that frowns on race- based distinctions. By contrast, the VA system is less closely associated with the active military. As such, its providers (and patients) are civilians. Therefore, they are influenced by social and cultural factors similar to other health care settings. Further exploration of racial disparities in the VA system compared with the active military system may be fruitful in understanding the etiology of racial disparities in health care. Disparities in Health Care Services and Quality Racial and ethnic differences in access and utilization of health services comprise the largest category of studies of disparities in health care. After controlling for numerous individual factors, Shi (Shi, 1999) showed that minority populations were 1.46 times more likely to identify their usual source of care as a facility rather than a person. In addition, minorities in general and Hispanics in particular were less likely than Whites to indicate that their usual care providers listened to them. Cornelius and Collins (Cornelius and Collins, 2000)
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3: MEASURING DISPARITIES 79 found substantial differences by race and ethnicity in health insurance status and having a usual source of care. Blendon et al. (Blendon et al., 1989) found racial differences in access to care across all income groups and demonstrated severe underuse of services among African Americans. If racial and ethnic disparities in health status are to be eliminated, access and availability of health care are major considerations. These issues are largely related to differences in socioeconomic status among racial and ethnic groups and the continuation of public policies that link health insurance to employment or citizenship. However, the problem of racial and ethnic disparities in health care extends beyond access to health care facilities. It also includes disparities in the availability of health care resources in the facilities where racial and ethnic minorities receive care. As indicated in Unequal Treatment (TOM, 2002), there is a large literature demonstrating racial and ethnic disparities in access to specific medical procedures after patients have entered the health care system. This literature is a diverse amalgam of studies documenting disparities in primary care (Moore et al., 1994), specialty care (McAlpine and Mechanic, 2000), surgical procedures (Escarce et al., 1993; Lee et al., 1998; McBean and Gornick, 1994), and inpatient education (Cowie and Harris, ~ 997~. In 2000 Mayberry and associates published a comprehensive review of the literature on racial disparities in health care, focusing on studies published between 1985 and 1999 (Mayberry et al., 2000~. The article summarized a large number of studies documenting disparities across a wide variety of health conditions. Disparities were documented in health services for heart disease, stroke, cancer, diabetes, HIV/AIDS, prenatal care, immunizations, asthma, and mental health services. The conditions studied by Mayberry et al. conform to the major health conditions examined in the Report of the Secretary's Task~force or' Black and Minority Health (DHHS, 1985~. Others have reviewed the literature as it relates to specific conditions and procedures. For example, Homer et al. (Homer et al., 1995) reviewed the literature on race disparities in health care for stroke patients, and Sheifer et al. (Sheifer et al., 2000) examined studies of racial disparities in access to coronary angiography. And still others
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80 GUIDANCE FOR THE NATIONAE HEALTH CARE DISPARITIES REPORT conducted studies of disparities across numerous procedures to test for those that demonstrated major disparities compared to those that did not (Escarce et al., 1993; Lee et al., 1998; McBean and Gornick, 1994). To identify documented areas in health care with the greatest and least health disparities, each of these types of reviews was examined. The results of this examination of the literature are summarized in Table 3-~. Table 3-l reports selected studies of areas of health care with the largest and best-documented disparities. The best-documented disparities in health care may be those that relate to procedures for cardiovascular disease. Coronary angiography is a procedure of particular importance. Heart disease is the leading cause of death in the United States, and coronary angiography is essentially a prerequisite for percutaneous transluminal coronary angioplasty (PTCA) or coronary bypass surgery. Perhaps most striking is the finding of racial disparities in the use of coronary angiography within the VA (Peterson et al., 1994; Sedlis et al., 1997~. This is because access to care is similar for all, and there is no economic incentive for either the patient or the provider related to care. Cancer is also a condition with a large number of documented disparities in the quality of care. For example, Burns et al. (Burns et al., 1996) found that African American women were less likely than White women to receive mammography even after adjusting for use of primary care. Cooper et al. (Cooper et al., 1996) found that a higher proportion of White colorectal cancer patients (78 percent) underwent surgical resection than their African American counterparts (68 percent). Earie et al. (EarIe et al., 2002) found disparities in race and socioeconomic status in referral patterns for chemotherapy among lung cancer patients. And Harlan et al. (Harlan et al., 1991) found that Hispanic women were less likely to receive Pap smears than White women. 1 It should be noted that variability across sample populations, settings, and databases in the studies reviewed can affect overall conclusions and generalizations on racial and ethnic health care disparities.
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3: MEASURING DISPARITIES 81 Other procedures related to major causes of death and/or disability include diagnostic and therapeutic procedures for cerebrovascular disease (Eggers, 1995; Homer et al., 1995), renal transplantation (Epstein et al., 2000), HIV antiretroviral therapy (Moore et al., 1994), asthma (All and Osberg, 1997), and participation in AIDS clinical trials (Stone et al., 1997~. Marsh et al. (Marsh et al., 1999) found that physicians were twice as likely to recommend hormone replacement therapy for White patients than Blacks. And Todd et al. (Todd et al., 2000) demonstrated that 43 percent of African American patients with extremity fractures at one university hospital went untreated for pain, while only 26 percent of White patients with similar fractures went untreated. A similar study by Todd et al. (Todd et al., 1993) found that White patients with broken bones were 64 percent more likely to receive pain medication than Hispanic patients with similar fractures. Additionally, in a recently published article, Edelstein (Edelstein, 2002) documented continuing disparities in dental health care. This is consistent with national reports showing disparities in untreated caries for African Americans and Hispanics compared with Whites (Eberhart et al., 2001~. Gornick's (Gornick, 2000) study of trends in racial differences in receipt of selected health care procedures among Medicare recipients showed that ten of the thirteen procedures examined exhibited increasing disparities over time. Two procedures showed decrease and one disparity remained the same. It can be concluded from studies of racial and ethnic differences in access and utilization of health services that racial and ethnic minorities often face the prospect of seeking care in facilities with fewer resources. And, when they obtain access to similar facilities, they often receive less optimal treatment than nonminorities.
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84 GUIDANCE FOR THE NATIONAL HEALTHCARE DISPARITIES REPORT Hyperdisparities in Health Care Services and Quality In an update of a 1996 study, Gornick (Gornick, 2000) examined trends in racial differences in the use of health services by Medicare beneficiaries during the 1990s. Gornick (Gornick, 2000) demonstrated three hyperdisparities: amputation of the lower limb, arteriovenostomy, and excisional debridement. One set of analyses (see Table 3-2 for information on some analyses) found that, in each case, the disparities actually increased between 1986 and 1994. McBean and Gornick (McBean and Gornick, 1994) found that bilateral orchiectomy was also more commonly used in African American patients. The ratio of Blacks to Whites was I .57 in 1986 and 2.47 in 1992. TABLE 3-2 Hyperdisparities among Medicare Enrollees Age 65 and Over BLAC K/WHITE BLAC K/WHITE 1994- 198 6 PROCEDURE RATIO OF RATIO OF HYPERDISPARITY R A T E S : R ~ T E S : D I F F E R E N C E 1986 1994 Amputation of 3.24 3.47 .23 Lower Limb A r t e r i o v e n o s t o m y 4 . 0 2 4 . 5 3 . 5 1 Excisional 2.36 2.51 .15 Debridement SOURCE: (Go~nick, 20001. Culler et al. (Curler et al., 1998) examined Medicare administrative records to identify patient characteristics associated with potentially preventable hospitalizations and found that Afiican American patients were more likely to have such hospitalizations. Brennan et al. (Brennan et al., ~ 99 ~ a; Brennan et al., ~ 991b) found that hospitals that serve primarily minority patients have similar rates of adverse events compared to those hospitals that do not treat predominantly minority populations. Yet these same hospitals have significantly higher rates of adverse events due to medical negligence or errors compared to those hospitals not treating predominantly minority patients. Even after controlling for hospital characteristics and for disease severity and complexity, the only factor that remains
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3: MEASURING DISPARITIES 85 consistently associated with an increased risk of adverse events due to negligence is a large proportion of discharged minority patients. 3-2. CREATING A NATIONAL HEALTHCARE DISPARITIES REPORT There are numerous factors to consider in determining the types of disparities that should be the focus of the NHDR. Since the report will need to rely on existing data sources (at least in the short term), this presents a set of limitations that may hinder the utility of the report. Many existing data sources can be used to adequately measure morbidity, mortality, and health risks such as smoking and obesity. However, there are fewer national databases that can be used to measure health care indicators. The Centers for Medicare and Medicaid Services (CMS) offer a good source of data on health care disparities among the elderly. Similarly, the Medical Expenditure Panel Survey (MEPS), the Healthcare Cost and Utilization Project (HCUP), and the National CAMPS (Consumer Assessment of Health Plans) Benchmarking Database (NCBD) are all potential sources of data, at least in the short term. But sources of national data on disparities in underuse or overuse of specific medical procedures for non-Medicare or Medicaid populations are still more limited. in establishing criteria for the selection of measures for the NHDR, there are a variety of factors to consider. One might select procedures with the highest costs or those that are the most thoroughly documented. One might also select procedures associated with conditions with the highest mortality rates or the greatest number of years of potential life lost. However, these approaches are somewhat problematic. Years of potential life lost would tend to select causes of death for younger Americans such as nonchronic conditions and homicides, accidents, and injuries. These are important, but tertiary considerations. Rather, a conceptual framework should be used that combines the continuum of health care disparities (equalities, disparities, and hyperdisparities) with the four consumer perspectives on health care needs, as discussed in Envisioning the National Healthcare Quality Report (IOM, 2001~. The continuum of disparities would range from equality, or the absence of disparities; to disparities,
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88 GUIDANCE FOR THE NATIONAL HEALTHCARE DISPARITIES REPORT 1989), glaucoma (Iavitt et al., 1991), and psychiatric conditions (Chung et al., ~ 995~. Health Status Outcomes A growing body of health care quality data suggests that iatrogenic injury should be considered an important component of the total quality of care picture. The literature indicates that a significant proportion of adverse events are due to errors in medical judgment that result in delivered care that is Tower than commonly accepted medical standards. Those events that result in significant disability, morbidity, and/or mortality to the patient are by definition said to be due to negligence (Brennan et al., l99la; Brennan et al., 199lb). HCUP (although geographically limited) is an example of data that can be used to produce estimates of components of health care quality from hospital discharge data. Approaches to Reporting It is important that the data are reported in a way that is accessible to policy makers and the general public. The U.S. Department of Labor produces a set of economic indicators that is closely watched and widely regarded as a gauge of the economic status of the country (for example, the Consumer Price Index, the Employment Cost Index, the Employment Situation, the Producer Price Index, Productivity and Costs, Real Earnings, and the U.S. Import and Export Price Indexes). It is possible to create such measures for health status, health care quality, and disparities that could serve as "the health disparities index." There is some experience with such measures in health, including the World Health Organization's "Global Burden of Disease" project. One undesirable aspect of "global measures" is that it is inevitable that they will mask some degree of variability (Nygaard, 2000~. However, such a measure would be a valuable toot in informing the public and policy makers. An advantage of global measures is that they provide a summary statistic that is reflective of the general pattern of health care disparities, thereby avoiding details that may be unnecessary for policy makers and others to consider.
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3: MEASURING DISPARITIES 89 The specific computation of such an index is beyond the scope of this paper. It would be valuable to invest some resources in the creation of a set of global measures of health care disparities . These measures would aid in monitoring progress in improving the nation's health in general and eliminating health care disparities specifically. Additionally, such measures would eliminate the need to establish one racial and ethnic group (typically Whites) as a standard against which other groups are compared. The race-comparative approach has several undesirable aspects (as will be described below). The standard formats of reporting disparities used in health care research include risk ratios, odds ratios, and difference scores. Each of these methods has disadvantages. Table 3 - presents simulated data on use of cardiac catheterization among 250 Afiican American and White patients who were appropriate candidates for the procedure. To calculate the risk ratio (also called the rate ratio or ratio of rates), one would compute the ratio of the percentage of patients in each group who received catheterization. Thus Risk Ratio=.33 . 57.=.58 This statistic represents the risk of receiving catheterization for African Americans relative to Whites. However, it does not account for the possibility of overutilization of the procedure among Whites. TABLE 3-4 Simulated Data RECEIPT OF CARDIAC PATIENT PATIENT CATHETERIZATION RACE: RACE: TOTAL BLACK WHITE No. of Patients 75 175 250 No. Receiving Procedure 25 100 125 TO Receiving Procedure 33°/O \. 57% 50% Predicted % of Cardiac 30% 70% 100% Catheterizations Received by Group Observed % of Cardiac 20% 80% 100% Catheterizations Received by Group
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90 GUIDANCE FOR THE NATIONAL HEALTHCARE DISPARITIES REPORT A second standard approach is to compute the odds ratio. This statistic is computed by taking the ratio of the odds of receiving catheterization for one group relative to the other. Thus, the odds of receiving catheterization for African Americans are 25 . 50 = .5 and the odds for Whites are 100 - 75 = 1.33. The odds ratio is .5 . 1.33 = .38. This statistic represents the degree of disparity in the relative odds of getting catheterization. Like the risk ratio, it expresses disparity relative to Whites. A third approach is to take the simple difference in percentages for each group. Thus, 57 percent of Whites receive a procedure compared to 33 percent of African Americans: 57 - 33 = 24. A limitation to each of these approaches (besides again Using one group as the standard) is that the magnitude of the difference is not changed by qualitative differences in the rates. For example, 25 -1 = 24. Also, 100 - 76 = 24. . One approach to consider is the ratio of health care inequality. This statistic can be computed by first computing predicted and observed percentages of catheterization received by each group. This can be done as follows: determine the number of total patients that African Americans and Whites represent (75 - 250 = .3 X 100 = 30 percent for African Americans. For Whites, 175 . 250 = .7 X 100 = 70 percent). Since African Americans comprise 30 percent of the patients who need the procedure, one would expect they would receive 30 percent of the catheterizations. The degree to which the predicted percentage of catheterization deviates from the observed percentage indicates the degree of disparity in obtaining health care resources that were expended. Thus the ratio is produced by computing the ratio of observed to predicted catheterizations. For African Americans, 20 . 30 = .67, and for Whites, 80 - 70 = 1.14. It can be said, therefore, that African Americans received 67 percent of the catheterizations that they should have received, and Whites received 14 percent more than their share. This approach can be used to produce a unique score for each group, including Whites. Also, the score is easily understood. A score of 1 can be interpreted as equilibrium between observed and expected utilization. A score greater than 1 indicates that the procedure
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3: MEASURING DISPARITIES 91 is used in the group more than one would expect given a colorblind allocation of resource. 3-3. CONCLUSION This paper has presented issues for consideration in the development of the National Health Disparities Report. The considerations are summarized by the following suggestions. Create a framework for the categorization of health disparities that includes the continuum of health care equalities, disparities, and hyperdisparities as well as the four consumer perspectives on health care needs: staying healthy, getting better, living with illness or disability, and coping with the end of life (IOM, 2001~. In addition, adopt a set of criteria to use in the selection of individual measures. Criteria suggested include applicability to multiple racial and ethnic groups; accessibility to a broad population of health care consumers; limited confounding; and replicability.
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92 GUIDANCE FOR THE NATIONAL HEAETHCARE DISPARITIES REPORT Reference List All, S., and J.S. Osberg. 1997. Differences in follow-up visits between African American and white Medicaid children hospitalized with asthma. J Health Care Poor Underserved 8 (1~:83-98. Ayanian, J.Z., I.S. Udvarhelyi, C.A. Gatsonis, C.L. Pashos, and A.M. Epstein. 1993. Racial differences in the use of revascularization procedures after coronary angioplasty. JAMA 269 (20~:2642-46. Bach, P.B., D. Schrag, O. W. Brawley, A. Galaznik, S. Yakren, and C.B. Begg. 2002. Survival of blacks and whites after a cancer diagnosis. J~1MA 287 (16):2106-13. Bennett, C.L., R.D. Homer, R.A. Weinstein, G.M. Dickinson, J.A. DeHovitz, S.E. Cohn, H.A. Kessler, J. Jacobson, M. B. Goetz, and M. Simberkoff. 1995. Racial differences in care among hospitalized patients w~th Pneumocystis carinii pneumonia in Chicago, New York, Los Angeles, Miami, and Raleigh-Durham. Arch Intern Med 155 (15~: 1586-92. Blendon, R.J., L.H. Aiken, H.E. Freeman, and C.R. Corey. 1989. Access to medical care for black and white Americans. A matter of continuing concern. JAMA 261 (2~:278-81. Brennan, T.A., L.E. Hebert, N.M. Laird, A. Lawthers, K.E. Thorpe, L.L. Leape, A.R. Localio, S.R. Lipsitz, J.P. Newhouse, and P.C. Weiler. 1991a. Hospital characteristics associated with adverse events and substandard care. JAMA 265 (24~:3265-69. Brennan, T.A., L.L. Leape, N.M. Laird, L. Hebert, A.R. Localio, A.G. Lawthers, J.P. Newhouse, P.C. Weiler, and H. H. Hiatt. l991b. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. NEngl JMed 324 (6~:370-76. Bullard, R.D. 1983. Solid waste sites and the black Houston community. Sociol Inq 53 (2-3~:273-88. Burns' R.B., E.P. McCarthy, K.M. Freund, S.L. Marwill, M. Shwartz, A. Ash, and M.A. Moskowitz. 1996. Black women receive less mammography even wi~ similar use of primary care. Ann Intern Med 125 (3~: 173-82. Chung, H., J. C. Mahler, and T. Kakuma. 1995. Racial differences in treatment of psychiatric inpatients. Psychiatr Serv 46 (6~:586-91.
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3: MEASURING DISPARITIES Cleary, P. D., and S. Edgman-Levitan. 1997. Health care quality. Incorporating consumer perspectives. JAMA 278 ~ 19~: 1608- 12. 93 Cooper, G. S., Z. Yuan, C. S. Landefeld, and A.A. Rimm. 1996. Surgery for colorectal cancer: race-related differences in rates and survival among Medicare beneficiaries. Am J. Public Health 86 (49:582-86. Cornelius, L. L. and K. S. Collins. 2000. Financial barriers for working-age minority populations: poverty and beyond. In Minority Health in America: Findings and Policy Implications from The Commonwealth Fund Minority Health Survey . Ed. Hogue, C.J.R., M.A. Hargraves, and K.S. Collins. Baltimore: Johns Hopkins University Press. Cowie, C.C. and M.I. Harris. 1997. Ambulatory medical care for non- Hispanic whites, African-Americans, and Mexican-Americans with NIDDM in the U.S. Diabetes Care 20 (2~:142-47. Cutler, S.D., M.L. Parchman, and M. Przybylski. 1998. Factors related to potentially preventable hospitalizations among the elderly. Med Care 36 (6~:804-17. DHHS "Department of Health and Human Services] . 1985. Report of the Secretary's Task Force on Black and Minority Health. Washington DC: DHHS. Dominitz, J.A., G.P. Samsa, P. Landsman, and D. Provenzale. 1998. Race, treatment, and survival among colorectal carcinoma patients in an equal- access medical system. Cancer 82 (12~:2312-20. Earle, C.C., P. J. Neumann, R.D. Gelber, M.C. Weinstein, and J.C. Weeks. 2002. Impact of referral patterns on the use of chemotherapy for lung cancer.JClinOncol 20~7~:1786-92. Eberhart, M.S., D.D. Ingram, and D.M. Makuc. 2001. Urban and Rural Health Chartbook, Health, United States, 2001. Hyattsville, MD: National Center for Health Statistics. Edelstein, B.L. 2002. Disparities in oral health and access to care: findings of national surveys. Ambul Pediatr 2 (2 Suppl): 141-47. Eggers, P.W. 1995. Racial differences in access to kidney transplantation. Health Care Financ Rev 17 (24:89-103.
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