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Racial and Ethnic Disparities in Diagnosis and Treatment: A Review of the Evidence and a Consideration of Causes H. Jack Geiger, M.D. City University of New York Medical School INTRODUCTION At no time in the history of the United States has the health status of minority populations—African Americans, Native Americans and, more recently, Hispanics, and several Asian subgroups—equaled or even ap- proximated that of white Americans. The health of all American racial and ethnic groups has improved dramatically, particularly over the last six decades, but the paired burdens of excess morbidity and decreased life expectancy for people of color have been noted over several centuries and have proved, even recently, to be stubbornly resistant to substantial change (Byrd and Clayton, 2000; National Center for Health Statistics, 1998). Two observations, some four decades apart, illustrate this persis- tence of inequality. In his classic 1944 study of the role of race in American life, Gunnar Myrdal noted that “Area for area, class for class, Negroes cannot get the same advantages in the way of prevention and care of dis- ease that whites can” (Myrdal, 1944). In 1985, the Report of the Secretary’s Task Force on Black and Minority Health concluded that “Despite the unprecedented explosion of scientific knowledge and the phenomenal capacity of medicine to diagnose, treat and cure disease, Blacks, Hispan- ics, Native Americans, and those of Asian/Pacific Islander heritage have not benefited fully or equitably from the fruits of science or from systems responsible for translating and using health sciences technology” (USDHHS, 1985). In 1995, the overall African-American mortality rate was 60 percent higher than that of whites—precisely what it had been in 1950 (Williams and Rucker, 2000; Williams, 1999). 417
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418 UNEQUAL TREATMENT Classic public health doctrine holds that the major determinants of population health status and the primary explanations of disparities among population groups lie in the social, physical, and economic envi- ronments, which in turn are determined by the larger society’s norms, values, social stratification systems and political economy (King, 1996; Menefee, 1996). The causes of these minority/white disparities in health status have consistently been attributed to such variables as socioeco- nomic status (especially income, lack of education, and unemployment); lifestyle choices and behavioral risks; occupational and environmental hazards, inferior housing, poor nutrition, and different cultural beliefs about health and illness. There is evidence for all of these variables. An- other explanation is lack of minority access to health care, particularly the lack of either public or private health insurance, which has persisted de- spite the introduction and expansion of such programs as Medicare and Medicaid (Blendon et al., 1989; Weinick, Zuvekas, and Cohen, 2000). Two other variables frequently suggested as causative similarly re- flect values and beliefs that are prevalent in the larger society and appear with considerable frequency in the medical literature on disparities. The first of these is the contention that there are biologically and genetically distinct human races, and that “racial” biologic differences in susceptibil- ity to, manifestations of, or therapeutic responses to specific diseases are significant pathophysiologic contributors to health disparities. Such be- liefs appeared frequently in 19th-century America as elaborate, pseudo- scientific arguments for the inherent biological inferiority of African Americans (Cartwright, 1851). Today, however, despite the recognition that “race” is a social rather than a meaningful biologic concept (Marks, 1995; Cavalli-Sforza, Menozzi, and Piazzi, 1994; Witzig, 1996), arguments about the medical importance of racial groupings continue to appear, without pejorative intent and in highly sophisticated form (Wood, 2001; Schwartz, 2001; Goodman, 2000). The second suggestion is that racial and ethnic discrimination itself may be an important contributor to health disparities, not merely through the historic and persistent disadvantages it creates for minorities in the American social structure, but also specifically through health provider bias—conscious or unconscious, individual or institutional. A rich litera- ture attests to the persistence and prevalence of racist beliefs and discri- minatory behaviors in contemporary American society (Steinhorn and Diggs-Brown, 1999; Waller, 1998; Polednak, 1997; Massey and Denton, 1993; Hacker, 1992; Feagin, 1991; Farley and Allen, 1989). There was lim- ited quantitative evidence, however, for the view that such racial/ethnic discrimination might occur frequently in medicine until the availability of large administrative databases from Medicare, the Health Care Financing Administration (HCFA), the Department of Veterans Affairs (VA) and
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419 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT other sources initiated a growing stream of studies examining racial and ethnic disparities in diagnosis and treatment. These studies clearly estab- lished that whatever the causes, the experience of minorities within the health care system differed from that of comparable whites across a broad range of disease categories. The majority of these investigations focused on African-American patients; data on Hispanics, Native Americans, and Asian/Pacific Islanders were more limited. In 1990, the American Medical Association (AMA) took formal note of black-white disparities in health care. While emphasizing the probable roles of socioeconomic status and sociocultural factors and noting the limi- tations of many studies, the AMA also acknowledged that “Disparities in treatment decisions may reflect the existence of subconscious bias. . . . The health care system, like all other elements of society, has not fully eradicated this [racial] prejudice” (Council on Ethical and Judicial Affairs, 1990). Intense discussions of the early evidence and its possible causes, however, were already underway. A search of the literature prepared for the AMA’s board of trustees covering only the articles, commentaries and letters that appeared in the Journal of the American Medical Association and the New England Journal of Medicine from 1984 to 1994, filled 66 single-spaced pages (Board of Trustees Report 50-1, 1995). The comments of many physicians were heavily weighted toward denial. As van Ryn has pointed out, such reluctance is understandable because the idea that racial/ethnic bias might be operative conflicts with most physicians’ con- scious commitment to anti-discriminatory principles, their views of their own behaviors, that of their peers and the institutions within which they work, and the ethical commitments of medicine (van Ryn, 2001). Studies of racial/ethnic disparities in diagnosis and treatment prolif- erated throughout the 1990s and were characterized by increasingly so- phisticated control or adjustment for such confounding variables as health insurance status, income and education, severity or stage of disease, co- morbidity, and hospital type and resources. They drew upon a wide vari- ety of datasources, regional and multi-center collaborations, quality as- surance investigations, and disease-specific investigations such as the Coronary Artery Surgery Study (CASS). Relatively few were based on detailed access to clinical records. The limitations of administrative data- bases and retrospective methodologies usually precluded any evidence- based identification of the causes of disparities. Explanations, which were necessarily speculative in most cases, were drawn from the same repeti- tive list of possibilities. They included patient choice or preference, un- measured aspects of socioeconomic status, unmeasured clinical variables, biological differences in disease manifestation or response to treatment, minority cultural beliefs, lack of trust in the health care system, deficien- cies in providers’ cultural competence, and difficulties in cross-racial/
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420 UNEQUAL TREATMENT ethnic physician-patient communication, in addition to the possibility of individual or institutional bias. In the late 1990s, concerns about racial/ ethnic bias and stereotyping appeared with increasing frequency in the medical literature (Geiger, 1996, 1997; King, 1996; Smith, 1998; Williams and Rucker, 2000) and began to be presented as issues of social justice (McGary, 1999). Recently, local governments and public health depart- ments have conducted studies of racial/ethnic disparities and discrimina- tion in health care institutions in their own areas (Twin Cities Metro Mi- nority Health Assessment, 2001; Seattle and King County Public Health Department, 2001). At the federal level, Congressional legislation has spe- cifically addressed issues of discrimination in health care, and a new Na- tional Center on Minority Health and Health Disparities has been estab- lished at the National Institutes of Health. Clearly, the problem of racial/ ethnic disparities in diagnosis and treatment is increasingly being viewed as an important subset of the issue of achieving equity in health status (Department of Health and Human Services, 2000) and as a particularly troubling component of the problems of race and ethnicity in the larger society. It is in this context that systematic reviews of the relevant medical literature may help to illuminate three key questions. Does the cumula- tive weight of evidence establish that there are significant racial and ethnic differences in diagnostic investigation and therapeutic recommendations and actions, due at least in part to problems of bias and discrimination? If so, do such differences in health care in turn contribute to the excess bur- dens of morbidity, disability, impaired quality of life and premature mor- tality that are already so well documented in studies of the health status of minority populations? Finally, what can be determined about the mul- tiple processes and causes of these differences? The answers may be help- ful in addressing two additional questions: What are the needs for further research, and what steps might be taken now to reduce or eliminate such disparities? The Present Review: Scope and Methods This paper will present a sampling of findings from an ongoing re- view of the medical literature on racial and ethnic differences in diagnosis and treatment. Relevant studies were identified by searching Medline and many other databases, including those maintained by HCFA, the Agency for Healthcare Research and Quality (AHRQ), and the HHS Of- fice of Minority Health (OMH). Additional studies were identified through references in published articles. A substantial number of dedi- cated web sites relevant to issues of minority health, cultural competence and health workforce diversity were examined, as were a wide variety of
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421 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT reports from the Henry J. Kaiser Family Foundation, the Commonwealth Fund, the Association of American Medical Colleges (AAMC), the Na- tional Medical Association (NMA), the Hispanic Medical Association (HMA), and other organizations. Editorials, commentaries, and work- shop and conference reports were also reviewed. In all, more than 600 bibliographic citations have been accumulated and organized primarily by disease category. Topics include general medical care, coronary artery and other cardiac disease, cancer, cerebrovascular disease, asthma, HIV/ AIDS, renal disease and renal transplantation, diabetes, mental health, maternal and child health, ophthalmic disease, prevention, and a small sampling of other disease categories. An effort was made to identify all relevant studies comparing diagnosis and treatment by race or ethnicity, including any that did not report significant disparities. Additional topics include research methods and clinical trials, issues of trust and communi- cation in the healthcare system, and medical education and cultural competence. A hard copy of each article was obtained from the library and exam- ined for relevance, study design, appropriateness of data sources, ana- lytic methods and control of potentially confounding variables, and origi- nality. Each selected article was then reviewed by at least two people—a physician with epidemiologic training and a master’s or doctoral level epidemiologist or health services researcher. A detailed one- or two-page annotation was then prepared, including not only the material usually presented in the abstracts—purpose, data sources, study design, methods and results—but also important details from the text such as the discus- sions, the offered explanations, the acknowledged limitations, and any statements of implications for policy or research. Initial support for this work was provided by the Robert Wood Johnson Foundation, and sup- port for what is now an ongoing effort has been provided by the Josiah Macy, Jr., Foundation, the Commonwealth Fund, the Ford Foundation, and the W.K. Kellogg Foundation. This effort substantiates and extends the pioneering work of Mayberry and his associates, who published the first detailed and comprehensive review of the relevant medical literature (Mayberry, Mili, and Ofili, 2000). As indicated by the list of topics, the scope of the present effort was some- what broader, as was the time frame. A few studies and commentaries, mostly in the psychiatric literature, were found in the 1960s (Gross and Herbert, 1969; Pasamanick 1963) and a small number of relevant publica- tions appeared in the 1970s. The majority of articles selected for this re- view, however, were published between 1980 and the first half of 2001. Our purpose in the following sections is not to present an exhaustive account or description of each annotation in every topic category, a task that would require a much longer paper. Instead, a modest number of
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422 UNEQUAL TREATMENT studies, selected as representative of the most important findings, will be described and discussed in the following section on general medical and surgical care. This will give some sense of the data sources, study designs and methods that are typical of the entire research effort. In subsequent sections, an attempt will be made to present representative studies in each of five disease categories. These examples from the literature review are intended to document the multiplicity of factors, including but by no means limited to individual and institutional bias, that contribute to racial and ethnic disparities in diagnosis and treatment. General Medical and Surgical Care Perhaps the most useful data come from large-scale studies that ex- amine racial/ethnic differences in the adequacy, intensity and quality of diagnostic and therapeutic procedures for a wide range of clinical condi- tions, in different hospital types and health care systems For example, Kahn and her colleagues examined the quality of care provided to a na- tionally representative sample of 9,932 elderly Medicare-insured benefi- ciaries. The sample included patients who were black or from poor com- munities and who had been hospitalized for congestive heart failure, pneumonia, acute myocardial infarction or stroke, in one of 297 acute care hospitals—urban teaching, urban nonteaching, or rural—in five states (Kahn et al., 1994). The study is noteworthy for its detailed examination of clinical records, and its use of explicit quality criteria to assess the most basic (not luxury) elements of care: history taking and physical examina- tion, common diagnostic tests such as chemistries and chest X-rays, and standard therapies such as diuretics and antibiotics. Because the care of black and poor patients was found to be similar, the two groups were combined in the analysis. When the experience of these patients was com- pared with that of people who were white or more affluent, the quality of care as measured by these fundamental indicators was found to be sig- nificantly lower for the black and poor group. While quality of care was best in urban teaching hospitals, the magnitude of the quality gap was similar in all three hospital types. The authors noted that further research is necessary to clarify whether sociocultural and educational incongruity between providers and patients translates into misunderstandings about patients’ preferences and expectations, and to evaluate the extent to which stereotyping, discrimination and bias exist in the hospital setting. They concluded that “racial characteristics and poverty status also influence the quality of care received by acutely ill, insured patients after they have gained access to the hospital.” A number of similar studies examined black-white differences in the use of selected specific procedures. Lee and colleagues reviewed the use
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423 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT of both basic and sophisticated diagnostic tests and minor and major sur- gical procedures, using claims data for Medicare beneficiaries in 10 states and the District of Columbia who had both Part A and Part B coverage. A subset of this sample was created by matching beneficiaries on the basis of zipcode of residence to neutralize the effects of black-white differences in provider access and regional practice patterns. Despite the adequacy of health insurance coverage, black patients’ utilization was substantially weighted toward lower-cost procedures. The authors concluded that “...providers appear to be giving less intensive care to otherwise similar black Medicare beneficiaries” (Lee et al., 1997). Similarly, McBean and Gornick studied the use of 17 major diagnostic and therapeutic proce- dures and found that black Medicare beneficiaries were much less likely than whites to receive “referral-sensitive surgeries” (McBean and Gornick, 1994). One of the largest studies reviewed more than 1.7 million hospital discharge abstracts to examine use of major diagnostic and therapeutic procedures in 77 disease categories in some 500 acute care hospitals (Harris, Andrews, and Elixhauser, 1997). After controlling for patient age, severity of illness, health insurance and hospital type, blacks were signifi- cantly less likely than whites to receive a major therapeutic procedure in almost half of the 77 disease categories. Again, in a five percent sample of more than 1.2 million claims in a HCFA Medicare database, blacks were found less likely than whites to receive 23 of 32 services, and the dispari- ties were found even when patients were insured by both Medicare and Medicaid, minimizing the confounding of race with financial barriers to care (Escarce and Epstein, 1993). In a study of racial variation in proce- dures characterized as low, moderate or high physician discretion (Mort, Weisman and Epstein, 1994), blacks were less likely to undergo even such low-discretion (i.e., clinically urgent) procedures as appendectomy and repair of an abdominal aortic aneurysm. Disparities are not limited to Af- rican Americans, however. After adjusting for socioeconomic status, a study comparing experiences of Hispanic with non-Hispanic patients in California, Florida, and New York found that Hispanics were less likely to undergo major procedures in 38 percent of 63 different disease catego- ries (Andrews and Elixhauser, 2000). A similar pattern was found even when very basic in-hospital diagnostic and therapeutic procedures for such common conditions as congestive heart failure and pneumonia were examined (Ayanian et al., 1999a). Using explicit process criteria and after adjustment, black Medicare patients were significantly less likely than whites to receive adequate laboratory and other diagnostic tests or thera- peutic drugs such as diuretics and antibiotics. Most of the investigations described above are broad-brush studies. Despite the consistency of their findings, and the indications that dispari-
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424 UNEQUAL TREATMENT ties may occur at every level of disease severity and at every stage of the diagnostic and therapeutic process, they have the limitations described previously. Most are retrospective, and cannot report information gleaned directly from providers or patients. Most have limited access to detailed clinical records, and so estimates of variables such as stage and severity of disease are likely to be approximations. There are serious prob- lems in controlling or adjusting adequately for socioeconomic status when data on individual patient income, education or occupation are limited or absent. Health insurance may fail to eliminate the financial barrier of out-of-pocket expenses, which may affect both patient and provider choices. And finally, these studies offer relatively little evidence on out- comes such as disability or subsequent mortality. These limitations underlie both the wide range and tentative nature of the explanations that are offered for the findings of racial and ethnic differences in care. The list is extraordinarily varied, but strikingly similar across studies. As noted previously, researchers suggest patient choice or preference; unmeasured socioeconomic variables; unmeasured clinical variables; unspecified sociocultural factors and differences in health be- liefs; and impaired physician-patient communication and interactions. Also frequently mentioned are financial barriers and procedure costs as disincentives to care; differences in provider type, practice patterns, refer- ral patterns and hospital resources; and overuse of procedures for whites rather than underuse for blacks. Yet, almost all the investigators also raise the possibility of racial bias and discrimination by providers, sometimes referring explicitly to racial and ethnic stereotyping. And many call for further research specifically designed to resolve the unanswered ques- tions of causation. A number of general surgical and orthopedic studies present similar findings. Blacks hospitalized in Maryland from 1985 to 1987 had lower rates for discretionary orthopedic, vascular, and laryngeal surgeries; the more discretionary the procedure, the lower the incidence among blacks. The differences were particularly marked for vascular surgery and were attributed to lower rates of referral and access to specialty care (Gittelsohn, Halpern, and Sanchez, 1991). A large retrospective cohort study of ampu- tation rates and leg-sparing surgery for peripheral vascular disease among African-American and white Medicare beneficiaries found that among both diabetics and nondiabetics, African Americans were significantly more likely than whites to undergo amputations and significantly less likely to receive lower-extremity arterial revascularization (Guadagnoli et al., 1995). A striking example of racially differential provision of advanced technology was reported in the free-care VA system, in which both pro- viders’ financial incentives and patients’ financial barriers are irrelevant and the socioeconomic spectrum of patients is substantially narrowed.
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425 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT Researchers examining a prospective clinical records file covering all VA hospitals with operating rooms studied the use of laparoscopic versus conventional open cholecystectomy (which has a much higher in-hospital death rate) in the first four years after the introduction of the newer method. After adjustment for age, coexisting disease, socioeconomic sta- tus, and potentially confounding clinical characteristics, African Ameri- cans were 32 percent less likely than whites to receive laparoscopic sur- gery (Arozullah et al., 1999). In several other studies, African Americans were significantly less likely to receive total hip or total knee replacements, although racial variation in disease incidence may account for some of the differences (Harris and Sledge, 1990; Wilson, May, and Kelly, 1994; Baron et al., 1996). A few studies reported particularly troubling outcomes. Hispanic pa- tients with long bone fractures in one teaching hospital emergency room were twice as likely as non-Hispanics to receive no medication for pain (Todd, Samaroo, and Hoffman, 1993). At least one study showed that mi- nority outpatients with cancer were provided with inadequate analgesic medication (Cleeland et al., 1997). Elderly African-American, Hispanic, Native Americans and Asian nursing home residents with cancer were also less likely to receive pain medication (Bernabei et al., 1998). Finally, in a national sample of intensive care units (ICUs) in the United States, African- American patients were found to receive significantly less treatment, less technological monitoring, fewer laboratory tests and less life-supporting treatments than whites in the first 24 hours in the ICU, after adjusting for type and severity of illness, age, and hospital characteristics (Williams et al., 1995). However, the researchers noted no black-white difference in overall ICU and hospital death rates. Finally, studies of hormone replacement therapy provide some in- sight into the contribution of physician-patient communication to differ- ences in care. Post-menopausal African-American women were not only less likely than white women to receive such treatment, but also less likely to receive counseling from physicians or be offered the choice of replace- ment therapy (Marsh et al., 1999; McNagney and Jacobson, 1997; Ganeson and Norris, 2000). Coronary Artery Disease Coronary artery disease (CAD) and acute myocardial infarction (AMI) are the most intensively and elaborately studied topics among all stud- ies of racial and ethnic differences in care. In the last 20 years close to 200 studies, reviews, editorials and commentaries have investigated or discussed disparities in cardiac catheterization, angioplasty, coronary ar- tery bypass surgery (CABG) and medical therapies such as the use of
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426 UNEQUAL TREATMENT beta-blockers, thrombolytic drugs, and aspirin. The reasons for the abun- dance of CAD-related studies are apparent. Coronary artery disease is a leading cause of death in all population groups. Its natural history, patho- physiology, risk factors and complications are well understood. There are relatively clear and standardized criteria for the appropriateness of inva- sive interventions and medical treatments. Utilization of these procedures and treatments is recorded in numerous databases, across all hospital types, and in many multicenter studies of specific diagnostic, treatment, or outcomes questions. Over the last decade, studies have been character- ized by increasingly sophisticated control or adjustment for confounders. With only a relative handful of exceptions (usually based on smaller samples), the pattern of results is clear: African Americans with CAD or AMI are significantly less likely to receive appropriate cardiac procedures or therapies (Maynard et al., 1986; Hannan et al., 1991; Udvarhelyi et al., 1992; Ayanian et al., 1993; Franks et al., 1993; Whittle et al., 1993; Peterson et al., 1994; Giles et al., 1995; Carlisle et al., 1995; Stone et al., 1996; Gornick et al., 1996; Sedlis et al., 1997; Weitzman et al., 1997; Peterson et al., 1997; Hannan et al., 1999; Canto et al., 2000). They are less likely to be catheter- ized. If they are catheterized, African Americans are frequently 20 per- cent to 50 percent less likely to undergo a revascularization procedure. They are less likely than whites to receive beta blockers, thrombolytic drugs, or aspirin. These findings occur in both teaching and nonteaching hospitals. Cumulatively, the studies have accounted for age, sex, disease severity, symptom expression, comorbidity, health insurance or payor, and physician specialty, though each of these has some effect on its own. Roughly similar but less consistent disparities have been found for His- panic patients (Goff et al., 1995; Mickelson et al., 1997; Canto et al., 1998; Hannan et al., 1999) but the documentation is less extensive; one study found no significant differences (Ramsey et al., 1997). Little difference in either invasive or medical treatment has been found between whites and Asians or Native Americans, but the number of studies is far too small to justify firm conclusions (Canto et al., 1998). It is worth noting again that most of this large body of evidence on disparities in the diagnosis and treatment of cardiac disease does not re- flect problems of primary access to health care, but are based on studies of persons already in the health care system. There is less certainty about the causes of these differences as the same varied explanations offered for differential treatment in general medical and surgical care tend to be presented in every disease category. Recent experimental and prospective studies, however, have clearly identified racial and ethnic bias or stereotyping in clinical decision making as a con- tributing factor (Schulman et al., 1999; van Ryn and Burke, 2000). One especially useful review of more than 25 major studies argues that while
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427 RACIAL AND ETHNIC DISPARITIES IN DIAGNOSIS AND TREATMENT the causes of these inequalities in care remain to be fully elucidated, the studies have clarified what does not explain them (East and Peterson, 2000). Thus, these authors conclude, the disparities are not due to differ- ences in disease prevalence because the treatment differentials are found in studies comparing black and white people with documented lesions or infarctions, and among those who have had access to cardiologists. They are not due to differences in clinical presentation, electrocardiographic findings, or size and distribution of coronary artery lesions. They are not fully explained by comorbidity or other clinical characteristics. They are not due to health insurance or payor type alone, since these disparities occur among equally insured Medicare patients and in VA hospitals where care is free. (Public hospital patients, however, who are dispropor- tionately minority, are less likely to receive revascularization procedures unless they have in-hospital access to a cardiologist. In other hospitals, such differences are not explained by physician specialty). Any patient whose primary admission is to a hospital with the requisite catheteriza- tion and operative facilities, however, is more likely to receive revas- cularization. The racial and ethnic disparities are not due to regional varia- tions, since they have been found in all areas of the country. They are not due to patient choice or refusal of procedures by minority patients; al- though a few studies of heart disease have found such an effect, more recent prospective studies have indicated that it is far too small to account for the large differences in treatment rates. The disparities are not due to overuse of appropriate treatments for whites and underuse for minori- ties, as inappropriate use does not vary by race. A uniquely detailed perspective on the complex sequence of events leading to decisions on revascularization—and the role of race at each stage in the process—is offered by a study of white, black and Hispanic patients, not on Medicare, who were discharged from California hospitals with a principal diagnosis of AMI during an eight-month period in 1991. The investigators divided the process into four phases: pre-hospital (ad- mission to a hospital offering revascularization); intra-hospital (initial ad- mission); inter-hospital (immediate transfer to a hospital offering revas- cularization), and post-hospital (re-admission for revascularization during ensuing months). At every stage, both race and payor status were power- ful predictors of revascularization (angioplasty and CABG). For example, within hospitals offering revascularization, whites and privately insured patients were most likely to receive revascularization; minority patients and the uninsured were least likely. Whites were also more likely to un- dergo transfer and revascularization than were minority patients. In the subgroup of patients who received a diagnostic cardiac catheterization, whites were almost 50 percent more likely than minority patients to have the procedure “converted” to a revascularization procedure. After ac-
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444 UNEQUAL TREATMENT Finally, the limitations of much of the research on disparities in race and ethnicity underscore the need for prospective studies, with access to detailed clinical records. This may be particularly important in under- standing the variations in verbal and nonverbal physician-patient com- munication in both race-concordant and race-discordant physician-patient dyads. Further research is essential, but implementation of corrective rec- ommendations now should not be held in abeyance. The raw discrimination and blatant racism described by Myrdal nearly six decades ago of relegating African Americans and other minor- ity patients to all-black hospitals, charity wards, or the basement wards of white hospitals have disappeared, but the scars of those past experiences remain, and subtler forms of differential treatment have emerged (Myrdal, 1944). As in other sectors of American society, the elimination of race/ ethnicity-based and class-based disadvantage in the health sector has al- ways been an unsteady march, rather than a seamless record of uninter- rupted progress. The documentation and further exploration of disparity is a step in an ongoing journey. REFERENCES Abreu J. Conscious and unconscious African American stereotypes: Impact on first impres- sion and diagnostic ratings by therapists. Journal of Consulting and Clinical Psychology. 1999;3:287-293. Alexander GC, Schgal AR. Barriers to cadaveric renal transplantation among blacks, women, and the poor. Journal of the American Medical Association. 1998;280:1148-1152. Anderson KH, Mitchell JM. Differential access in the receipt of antiretroviral drugs for the treatment of AIDS and its implications for survival. Archives of Internal Medicine. 2000;160:3114-3120. Anderson MR, Mloscou S, Fulchon C, Neuspiel DR. The role of race in the clinical presenta- tion. Family Medicine. 2001;33:430-434. Andrews R, Elixhuaser A. Use of major therapeutic procedures: are Hispanics treated differ- ently than non-Hispanic whites? Ethnicity & Disease. 2000;10:384-394. Arozullah AM, Ferreira MR, Bennett RL, et al. Racial variation in the use of laporoscopic cholecystectomy in the Department of Veterans Affairs medical system. Journal of the American College of Surgeons. 1999;188:604-622. Ayanian JZ, Udvarhelyi IS, Gatsonis CA, et al. Racial differences in the use of revas- cularization procedures after coronary angiography. Journal of the American Medical Association. 1993;269:2642-2646. Ayanian JZ, Weissman JS, Chasan-Taber S, Epstein AM. Quality of care by race and gender for congestive heart failure and pneumonia. Medical Care. 1999a;37:1260-1269. Ayanian JZ, Clearly PD, Weissman JS, Epstein AM. The effect of patients’ preferences on racial differences in access to renal transplantation. New England Journal of Medicine. 1999b;341:1661-1669. Bach PB, Cramer LD, Warren JL, Begg CB. Racial differences in the treatment of early-stage lung cancer. New England Journal of Medicine. 1999;341:1198-1205. Ball JK, Elixhauser A. Treatment differences between blacks and whites with colorectal can- cer. Medical Care 34. 1996;970-984.
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