Studies Look for Reasons Behind Racial Disparities in Health Care

By Christopher Lee
Washington Post Staff Writer
Wednesday, October 25, 2006

Racial minorities are less likely to undergo major surgeries at the hospitals where those operations are done best, and black patients at Medicare HMOs fare worse than whites on several health measures regardless of plan quality, according to studies being released today.

The two studies in today's issue of the Journal of the American Medical Association, plus a third showing that black women are less likely than their white counterparts to survive breast cancer, add to the voluminous evidence that the U.S. health-care system works differently for minorities than for whites despite years of efforts to erase racial disparities.

Studies have demonstrated that blacks and other minorities are far less likely than whites to receive many types of care, such as appendectomies, heart bypass surgery, or basic tests and drugs for heart disease and diabetes. Minorities on average are more prone to illness, have more complications and recover more slowly. They also are more likely to die from their illnesses, and to die younger.

But while the persistent disparities are well-documented, the causes remain the focus of research and debate. One explanation is that minorities tend to be poorer and less educated, with less access to care. And they tend to live in places where doctors and hospitals provide lower quality care than elsewhere. Others suspect cultural or biological differences play a role, and there is a long-running debate about whether subtle racism infects the health-care system.

Major medical organizations, private foundations and government health agencies have begun a host of studies, programs and initiatives in the past decade to try to close the gap.

In one new study, researchers at the UCLA medical school studied 719,608 patients who underwent one of 10 major operations -- including knee replacement, heart bypass and lung cancer surgeries -- over a five-year period.

They found that blacks, Hispanics and Asians were less likely than whites to receive care at hospitals that perform a high volume of the surgeries and excel in them. Minority patients were more likely to have their operations at low-volume hospitals, where mortality rates tend to be higher. The same was true for uninsured and Medicaid patients, who are disproportionately minorities.

"The current study demonstrates a significant disparity in the distribution of patients at high- and low-volume hospitals with respect to race/ethnicity and insurance status," the authors wrote.

The racial disparities remained even after accounting for income, age and how close a person lived to high- and low-volume hospitals. The researchers suggest that inadequate transportation or the lack of knowledge among minorities about hospital quality could be factors. Minorities are underrepresented among surgeons, and physicians who care for black patients are less likely to be board certified in a specialty and may have a harder time getting access to the better hospitals for their patients.

"Everyone wants to improve quality, but it's difficult," said Clifford Y. Ko, a co-author and professor of surgery at UCLA. "Not everyone can go to these high-volume places. . . . I personally think that instead of identifying one out of however many hospitals that people should go to that might have good outcomes, we should try to improve care at all hospitals."

A second study, led by Amal N. Trivedi, assistant professor of community health at Brown University, found that blacks do worse than whites in controlling blood pressure, blood sugar and cholesterol levels despite quality improvements at Medicare HMOs that have succeeded in shrinking gaps in care received by minorities and whites. The study, which looked at more than 430,000 patients in 151 plans, found that the disparity existed in both high- and low-quality Medicare HMOs -- undercutting the theory that blacks fare worse because they receive their care from lower quality providers.

"Across the board, black enrollees have lower performance on these measures," Trivedi said in an interview. "And the gaps were wide. . . . Even high-quality plans do not provide effective medical treatment for all of their patients."

Health plans should examine whether black patients lack access to medication or cannot afford it, because drugs can be effective in controlling conditions such as high cholesterol, blood pressure and blood sugar, Trivedi said. It also is worth trying to figure out whether black enrollees tend to get their care from lower-quality physicians within plans, he said.

"We can't say specifically why the gaps exist in each plan," Trivedi said. "It's probably a shared responsibility of plans, providers and patients. There's probably not one factor that explains all of the disparity, but health plans do play an important role."

In the breast cancer study, published online Monday in the journal Cancer, researchers from the University of Texas M.D. Anderson Cancer Center in Houston examined 2,140 patients who took part in clinical trails at the cancer center from 1975 to 2000. They found that black women had lower survival rates than white and Hispanic women, and that black patients had more advanced cancer at the time of treatment.

Previous studies with similar results have concluded that less frequent screening, less aggressive treatment and different access to care may be factors in lower survival rates for black women. But because all women in the new study received the same treatment, researchers think that breast cancer tumors may be more aggressive and less responsive to treatment in black women.

"These findings should prompt additional research on how we can improve outcomes for African American patients by understanding and addressing tumor biology," said Wendy Woodward, an assistant professor of radiation oncology at the cancer center and lead author of the study.

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