blacks (Wolinsky et al., 1989), and earlier studies report persistently higher use of hospitals by whites (Wan, 1982; Long and Settle, 1984). Nonetheless, all studies agree that racial differences in hospital utilization have narrowed markedly during the past three decades.
Two caveats are important in interpreting these encouraging trends. First, studies comparing rates of physician visits and hospitalization for black and white elders either have not adjusted for racial differences in health status (Davis et al., 1981; Wolinsky et al., 1989) or have used limited measures of physical health in the adjustment (Kleinman et al. 1981; Wan, 1982; Long and Settle, 1984; Furner, 1993). However, black-white differences in the health status of the elderly encompass multiple and varied dimensions of health. Older blacks not only have higher mortality rates than older whites; they also have higher rates of many common and frequently disabling chronic conditions, such as hypertension, diabetes, stroke, circulatory disease, end-stage kidney disease, arthritis and other musculoskeletal impairments, open-angle glaucoma, and certain cancers (Manton et al., 1987; Haywood, 1990; Anderson and Felson, 1988; Polednak, 1989; Leske and Rosenthal, 1979; Byrne et al., 1994). Not unexpectedly, blacks suffer from much more disability and functional impairment than whites (Manton et al., 1987). Black elders also have higher rates of mental and nervous disorders than whites (Manton et al., 1987; Polednak, 1989). Adjusting for racial differences in health status, therefore, requires more comprehensive health status measures than are generally employed. Failure to take a comprehensive approach may result in overlooking persistent and clinically important racial differences in medical care utilization.
Second, most of the studies focus on racial differences in the quantity of medical care received by older persons (e.g., numbers of physician visits and hospital nights) and do not address differences in the type or quality of care. Recent research has documented racial disparities in important qualitative aspects of medical care utilization. For instance, whereas white elders are more likely than black elders to obtain their regular ambulatory care from private physicians, blacks are more likely than whites to use neighborhood health centers, hospital outpatient departments, or emergency rooms (Wan, 1982; Kotranski et al., 1987). These practice settings are characterized by long waiting times, less satisfactory patient-physician relationships, and less continuity of care than private physicians' offices (Petchers and Milligan, 1988; Dutton, 1985).
In addition, elderly blacks are less likely than elderly whites to receive a wide array of specialized or high-technology medical services, including coronary angiography, angioplasty, and bypass surgery; carotid angiography and endarterectomy; cataract extraction; glaucoma surgery; hip and knee replacement; kidney transplantation; and magnetic resonance imaging (Wenneker and Epstein, 1989; Ford et al., 1989; Escarce et al., 1993; Ayanian et al., 1993; Kjellstrand, 1988; Javitt et al., 1991; Held et al., 1988; Oddone et al., 1993). Compared with white elders, hospitalized black elders receive worse processes of care, have