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Barriers to Eliminating Disparities in Clinical Practice

Lessons From the IOM Report “Unequal Treatment”
  • Joseph R. Betancourt
  • Angela Maina

Abstract

Over the last 200 yr, the United States has experienced dramatic improvements in overall health and life expectancy largely owing to initiatives in public health, health promotion, and disease prevention. Nevertheless, despite interventions that have improved the overall health of the majority of Americans, racial and ethnic minorities have benefited significantly less from these advances. National data indicates that minority Americans have poorer health outcomes (compared with whites) from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer, and HIV/AIDS, among others (1). Multiple factors contribute to these “racial and ethnic disparities in health.” First and foremost, research has demonstrated that social determinants such as lower levels of education, overall lower socioeconomic status, inadequate and unsafe housing, racism, and living in close proximity to environmental hazards disproportionately impact minority populations and thus contribute to their poorer health outcomes (2, 3, 4, 5, 6). One poignant example of the impact of social determinants is the fact that three of the five largest landfills in the country are in African American and Latino communities, thus contributing to some of the highest rates of pediatric asthma among these populations (7). Second, lack of access to care also takes a significant toll, as uninsured individuals are less likely to have a regular source of care, are more likely to report delay in seeking care, and are more likely to report that they have not received needed care—all resulting in experiencing avoidable hospitalizations, emergency hospital care, and adverse health outcomes (8, 9, 10).

Keywords

Limited English Proficiency Poor Health Outcome Ethnic Disparity Medical Encounter Unequal Treatment 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Eliminating Racial and Ethnic Disparities in Health (1998). Prepared by co-sponsors Grantmakers in Health for the DHHS conference: “Call to Action: Eliminating Racial and Ethnic Disparities in Health.” Potomac, MD.Google Scholar
  2. 2.
    Williams, D. R. (1990) Socioeconomic differentials in health: a review and redirection. Soc. Psych. 53, 81–89.CrossRefGoogle Scholar
  3. 3.
    Pincus, T., Esther, R., DeWalt, D. A., and Callahan, L. F. (1998) Social conditions and self management are more powerful determinants of health than access to care. Ann. Intern. Med. 129, 406–411.PubMedGoogle Scholar
  4. 4.
    Hinkle, L. E., Jr., Whitney, L. H., Lehman, E. W., et al. (1968) Occupation, education, and coronary heart disease. Risk is influenced more by education and background than by occupational experiences in the Bell System. Science 161, 23–46.CrossRefGoogle Scholar
  5. 5.
    Antonovsky, A. (1968) Social class and the major cardiovascular diseases. J. Chronic Dis. 21, 65–106.PubMedCrossRefGoogle Scholar
  6. 6.
    Pincus, T. and Callahan, L. F. (1995) What explains the association between socioeconomic status and health: primarily medical access or mind-body variables? Advances 11, 4–36.Google Scholar
  7. 7.
    Flores, G., Fuentes-Afflick, E., Oxiris, B., et al. (2002) The Health of Latino Children: Urgent Priorities, Unanswered Questions, and a Research Agenda. JAMA 288, 82–90.PubMedCrossRefGoogle Scholar
  8. 8.
    Andrulis, D. P. (1998) Access to care is the centerpiece in the elimination of socioeconomic disparities in health. Ann. Intern. Med. 129, 412–416.PubMedGoogle Scholar
  9. 9.
    Health Care Rx: Access for All. Barriers to Health Care for Racial and Ethnic Minorities: Access, Workforce Diversity and Cultural Competence. A Report Prepared by the Department of Health and Human Services and The Health Resources and Services Administration for the Town Hall Meeting on the Physician’s Initiative on Race (1998), Boston, MA.Google Scholar
  10. 10.
    American College of Physicians-American Society of Internal Medicine (ACP-ASIM) 2000. No Health Insurance? It’s Enough to Make You Sick. Philadelphia, PA: American College of Physicians-American Society of Internal Medicine.Google Scholar
  11. 11.
    US Census Bureau 2003. Insurance, Access, and Quality of Care Among Hispanic Populations (CWF). The Commonwealth Fund, http://www.cwnf.org accessed, March 2005.
  12. 12.
    Harris, D. R., Andrews, R., and Elixhauser, A. (1997) Racial and Gender Differences in Use of Procedures for Black and White Hospitalized Adults. Ethnicity Dis. 7, 91–105.Google Scholar
  13. 13.
    Peterson, E. D., Shaw, L. K., DeLong, E. R., Pryor, D. B., Califf, R. M., and Mark, D. B. (1997) Racial variation in the use Coronary-Revascularization Procedures. Are the differences real? Do they matter? N. Engl. J. Med. 336, 480–486.PubMedCrossRefGoogle Scholar
  14. 14.
    Ayanian, J. Z. and Epstein, A. M. (1991) Differences in the Use of Procedures Between Women and Men Hospitalized for Coronary Hearth Disease. N. Engl. J. Med. 325, 226–230.CrossRefGoogle Scholar
  15. 15.
    Schulman, K. A., Berlin, J. A., Harless, W., et al. (1999) The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization. N. Engl. J. Med. 340, 618–626.PubMedCrossRefGoogle Scholar
  16. 16.
    Johnson, P. A., Lee, T. H., Cook, E. F. et al. (1993) Effect of Race on Presentation and Management of Patients with Chest Pain. Ann. Intern. Med. 118, 593–601.PubMedGoogle Scholar
  17. 17.
    Todd, K. H., Samaroo, N., and Hoffman, J. R. (1993) Ethnicity as a Risk Factor for Inadequate Emergency Department Analgesia. JAMA 269, 1537–1539.PubMedCrossRefGoogle Scholar
  18. 18.
    Bernabei, R., Gambassi, G., Lapane, K., et al. (1998) Management of Pain in Elderly Patients with Cancer. JAMA 279, 1877–1882.PubMedCrossRefGoogle Scholar
  19. 19.
    Todd, K. H., Deaton, C., D’Adamo, A. P., and Goe, L. (2000) Ethnicity and analgesic practice. Ann. Emerg. Med. 35(1), 11–16.PubMedCrossRefGoogle Scholar
  20. 20.
    Bach, P. B., Cramer, L. D., Warren, J. L., and Begg, C. B. (1999) Racial differences in the treatment of early-stage lung cancer. N. Engl. J. Med. 341(16), 1198–1205.PubMedCrossRefGoogle Scholar
  21. 21.
    Ayanian, J. Z., Cleary, P. D., Weissman, J. S., and Epstein, A. M. (1999) The effect of patients’ preferences on racial differences in access to renal transplantation. N. Engl. J. Med. 341(22), 1661–1669.PubMedCrossRefGoogle Scholar
  22. 22.
    Ayanian, J. Z., Weissman, J. S., Chasan-Taber, S., and Epstein, A. M. (1999) Quality of care by race and gender for congestive heart failure and pneumonia. Med. Care 37(12), 1260–1269.PubMedCrossRefGoogle Scholar
  23. 23.
    Gornick, M. E., Eggers, P. W., Reilly, T. W., et al. (1996) Effects of Race and Income on Mortality and Use of Services among Medicare Beneficiaries. N. Engl. J. Med. 335, 791–799.PubMedCrossRefGoogle Scholar
  24. 24.
    Williams, D. R., Yu, Y., Jackson, J. S., and Anderson, N. B. (1997) Racial differences in physical and mental health: socioeconomic status, stress and discrimination. J. Health Psych. 2, 335–351.CrossRefGoogle Scholar
  25. 25.
    Institute of Medicine (2002). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press.Google Scholar
  26. 26.
    Berger, J. T. (1998) Culture and ethnicity in clinical care. Arch. Intern. Med. 158, 2085–2090.PubMedCrossRefGoogle Scholar
  27. 27.
    Eisenberg, J. M. (1979) Sociologic influences on medical decision making by clinicians. Ann. Intern. Med. 90(6), 957–964.PubMedGoogle Scholar
  28. 28.
    Stewart, M., Brown, J. B., Boon, H., Galajda, J., Meredith, L., and Sangster, M. (1999) Evidence on patient-doctor communication. Cancer Prev. Control 3(1), 25–30.PubMedGoogle Scholar
  29. 29.
    Betancourt, J. R., Carrillo, J. E., and Green, A. R. (1999) Hypertension in multicultural and minority populations: linking communication to compliance. Curr. Hypertens. Rep. 1, 482–488.PubMedGoogle Scholar
  30. 30.
    Commonwealth Fund Health Care Quality survey, 2001 http://www.cmwf.org/surveys [accessed, March 23, 2005].
  31. 31.
    Seijo, R. (1991) Language as a communication barrier in medical care for Latino patients. Hisp J Behav Sci. 13, 363.CrossRefGoogle Scholar
  32. 32.
    Perez-Stable, E. J., Napoles-Springer, A., and Miramontes, J. M. (1997) The effects of ethnicity and language on medical outcomes of patients with hypertension or diabetes. Med. Care 35(12), 1212–1219.PubMedCrossRefGoogle Scholar
  33. 33.
    Erzinger, S. (1991) Communication between Spanish-speaking patients and their doctors in medical encounters. Cult. Med. Psychiatry 15, 91.PubMedCrossRefGoogle Scholar
  34. 34.
    Crane, J. A. (1997) Patient Comprehension of doctor-patient communication on discharge from the emergency department. J. Emerg. Med. 15(1), 1–75.PubMedCrossRefGoogle Scholar
  35. 35.
    Carrasquillo, O., Orav, E. J., Brennan, T. A., and Burstin, H. R. (1999) Impact of language barriers on patient satisfaction in an emergency department. J. Gen. Intern. Med. 14(2), 82–87.PubMedCrossRefGoogle Scholar
  36. 36.
    Baker, D. W., Hayes, R., and Fortier, J. P. (1998) Interpreter use and satisfaction with interpersonal aspects of care for Spanish-speaking patients. Med. Care 36, 1461–1470.PubMedCrossRefGoogle Scholar
  37. 37.
    Baker, D. W., Parker, R. M., Williams, M. V., Coates, W. C., Pitkin, K. (1996) Use and effectiveness of interpreters in an emergency department. JAMA 275, 783–788.PubMedCrossRefGoogle Scholar
  38. 38.
    Hornberger, J., Itakura, H., and Wilson, S. R. (1997) Bridging language and cultural barriers between physicians and patients. Public Health Rep. 112(5), 410–417.PubMedGoogle Scholar
  39. 39.
    McKinlay, J. B., Potter, D. A., and Feldman, H. A. (1996) Non-medical influences on medical decisonmaking. Soc. Sci. Med. 42(5), 769–776.PubMedCrossRefGoogle Scholar
  40. 40.
    Hooper, E. M., Comstock, L. M., Goodwin, J. M., and Goodwin, J. S. (1982) Patient characteristics that influence physician behavior. Med. Care 20(6), 630–638.PubMedCrossRefGoogle Scholar
  41. 41.
    van Ryn, M. and Burke, J. (2000) The effect of patient race and socio-economic status on physician’s perceptions of patients. Soc. Sci. Med. 50, 813–828.PubMedCrossRefGoogle Scholar
  42. 42.
    Weisse, C. S., Sorum, P. C., Sanders, K. N., and Syat, B. L. (2001) Do gender and race affect decisions about pain management? J. Gen. Intern. Med. 16, 211–217.PubMedCrossRefGoogle Scholar
  43. 43.
    Schulman, K. A., Berlin, J. A., Harless, W., et al. (1999) The effect of race and sex on physicians’ recommendations for cardiac catherization. N. Engl. J. Med. 340, 618–626.PubMedCrossRefGoogle Scholar
  44. 44.
    Cooper-Patrick, L., Gallo, J. J., Gonzales, J. J., et al. (1999) Race, gender, and partnership in the patient-physician relationship. JAMA 282(6), 583–589.PubMedCrossRefGoogle Scholar
  45. 45.
    Einbinder, L. C. and Schulman, K. A. (2000) The effect of race on the referral process for invasive cardiac procedures. Med. Care Res. Rev. 1, 162–177.CrossRefGoogle Scholar
  46. 46.
    Eisenberg, J. M. (1979) Sociologic influences on medical decision making by clinicians. Ann. Intern. Med. 90(6), 957–964.PubMedGoogle Scholar
  47. 47.
    Morales, L. S., Cunningham, W. E., Brown, J. A., Liu, H., and Hays, R. D. (1999) Are Latinos less satisfied with communication by health care providers? J. Gen. Intern. Med. 14, 409–417.PubMedCrossRefGoogle Scholar
  48. 48.
    Rathore, S. S., Lenert, L. A., Weinfurt, K. P., et al. (2000) The effects of patient sex and race on medical students’ ratings of quality of life. Am. J. Med. 108, 561–566.PubMedCrossRefGoogle Scholar
  49. 49.
    Chen, J., Rathore, S. S., Radford, M. J., Wang, Y., and Krumholz, H. M. (2001) Racial differences in the use of cardiac catheterization after acute myocardial infarction. N. Engl. J. Med. 344, 1143–1449.CrossRefGoogle Scholar
  50. 50.
    Finucane, T. E. and Carrese, J. A. (1990) Racial bias in presentation of cases. J. Gen. Intern. Med. 5, 120–121.PubMedCrossRefGoogle Scholar
  51. 51.
    Wennberg, J. E. (1999) Understanding geographic variations in health care delivery. N. Engl. J. Med. 340, 32–39.CrossRefGoogle Scholar
  52. 52.
    Fiske, S. T. and Taylor, S. E. (1991) Social Cognition (2nd ed.), New York: McGraw-Hill.Google Scholar
  53. 53.
    Fiske, S. T., Gilbert, D. T., Fiske, S. T., and Lindzey, G. Stereotyping, Prejudice, and Discrimination (chapter). In: Gilbert, D. T., Fiske, S. T. et al., (eds.) The Handbook of Social Psychology, Vol. 2 (4th ed.), New York: McGraw-Hill pp. 357–411.Google Scholar
  54. 54.
    van Ryn, M. and Fu, S. S. (2003) Paved with good intentions: do public health and human service providers contribute to racial/ethnic disparities in health? Am. J. Public Health 93, 248–255.PubMedGoogle Scholar
  55. 55.
    Macrae, C. N., Milne, A. B., and Bodenhausen, G. V. (1994) Stereotypes as energy saving-devices: A peek inside the cognitive toolbox. J. Pers. Soc. Psychol. 66(1), 37–47.CrossRefGoogle Scholar
  56. 56.
    Geiger, H. J. (2001) Racial Stereotyping and Medicine: The Need for Cultural Competence. CMAJ 164(12), 1699–1700.PubMedGoogle Scholar
  57. 57.
    Branch, W. T. Jr. (1998) Professional and moral development in medical students: the ethics of caring for patients. Trans. Am. Clin. Climatol. Assoc. 109, 218–229; discussion 229 and 230.PubMedGoogle Scholar
  58. 58.
    The Henry J. Kaiser Family Foundation (1999). Race, Ethnicity, and Medical Care: Improving Access in a Diverse Society. http://www.kff.org (Accessed January 12, 2006)
  59. 59.
    Institute for Medicine (2000). “To Err is Human: Building a Safer Health System”. Washington, DC: National Academy Press. http://www.nap.org (Accessed January 12, 2006)Google Scholar
  60. 60.
    Dracup, K. and Bryan-Brown, C. W. (2002) On notebooks and trust. Am. J. Crit. Care 11(2), 96, 98, 100.PubMedGoogle Scholar
  61. 61.
    Berens, M. J. (2000) Nursing mistakes Kill, injure thousands. Chicago Tribune.Google Scholar
  62. 62.
    Rock, A. (2001) How hospitals are gambling with your life. Reader’s Digest 151–168.Google Scholar
  63. 63.
    Peterson, L. A. (2002) Racial Differences In Trust: Reaping What We have Sown. Med. Care 40(2), 81–84.CrossRefGoogle Scholar
  64. 64.
    Thom, D. H. and Campbell, B. (1997) For the Stanford Trust Study Physicians. Patient-Physicians Trust: An Exploratory Study. J. Fam. Pract. 44, 169–176.PubMedGoogle Scholar
  65. 65.
    Safran, D. G., Taira, D. A., Rogers, W. H., Kosinski, M., Ware, J. E., and Tarlov, A. R. (1998) Linking Primary Care Performance to Outcomes of Care. J. Fam. Pract. 47, 213–220.PubMedGoogle Scholar
  66. 66.
    Gamble, V. (1997) Under the shadow of Tuskegee: African-Americans and health care. Am. J. Public Health 87(11), 1773–1778.PubMedCrossRefGoogle Scholar
  67. 67.
    Corbie-Smith, G. (1999) The continuing legacy of Tuskegee Syphilis Study: considerations for clinical investigation. Am. J. Med. Sci. 317, 5–8.PubMedCrossRefGoogle Scholar
  68. 68.
    Brandt, A. M. (1978) Racism and research: the case of the Tuskegee syphilis study. Hastings Cent. Rep. 8, 21–29.PubMedGoogle Scholar
  69. 69.
    Race, Ethnicity and Medical Care (2005). A Survey of Public Perceptions and Experiences (KFF) Kaiser Family Foundation, http://www.kff.org accessed, March 11 2005.
  70. 70.
    National Survey of Physicians, Part One: Doctors on Disparities in Medical Care. (KFF). Kaiser Family Foundation, http://www.kff.org. accessed, March 11 2005.
  71. 71.
    Corbie-Smith, G., Thomas, S. B., and St. George, D. M. (2002) Distrust, Race, and Research. Arch. Intern. Med. 162, 2458–2463.PubMedCrossRefGoogle Scholar
  72. 72.
    Arday, S. L., Arday, D. R., Monroe, S., and Zhang, J. (2000) HCFA’s Racial and Ethnic Data: Current Accuracy and Recent Improvements. Health Care Financ. Rev. 21(4), 107–116.PubMedGoogle Scholar
  73. 73.
    Manson, A. (1988) Language concordance as a determinant of patient compliance and emergency room use in-patients with asthma. Med. Care 26, 1119–1128.PubMedCrossRefGoogle Scholar
  74. 74.
    Physicians by Race/Ethnicity 2000. AMA Physician Characteristic and Distribution in the US 2002–2003 ed, total. http://www.ama-assn.org/ama/pub/category/2672.html. (Accessed November 16, 2005)
  75. 75.
    Distribution of US Medical School Faculty by Race/Ethnicity, 1980 to 2001. AAMC Faculty Roster System, December 2001. http://www.aamc.org/data/facultyroster/usmsfol/start.htm. Accessed November 16, 2005.
  76. 76.
    US Medical School Graduated, 2001. AAMC Student Record System, April 2002. http://www.aamc.org/programs/srs/start.htm. Accessed November 16, 2005.

Copyright information

© Humana Press Inc. 2007

Authors and Affiliations

  • Joseph R. Betancourt
    • 1
    • 2
    • 3
    • 4
  • Angela Maina
    • 5
  1. 1.The Disparities Solutions CenterUSA
  2. 2.The Institute for Health PolicyUSA
  3. 3.Massachusetts General HospitalUSA
  4. 4.Harvard Medical SchoolBoston
  5. 5.Department of Multicultural EducationMassachusetts General HospitalBoston

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