Despite efforts, racial gap still plagues health care
Studies show improvement under managed care
A recently published study of the effects of managed care on delivery of health care and screenings to enrollees found that it appears to improve care across the board. Particularly heartening are indications that the disparity in care given to white enrollees vs. black enrollees was narrowed sharply.
But two other studies that appear alongside the study on managed care in the Aug. 18, 2005, issue of New England Journal of Medicine demonstrate that there’s still cause for concern about racial and ethnic disparities in U.S. health care.
Separate studies from researchers at Emory University in Atlanta and Harvard University in Boston indicate that black patients are less likely than whites to receive lifesaving treatments after heart attacks, to have blood glucose levels controlled, and to receive hip and knee replacements.
And despite race and ethnicity having been identified two decades ago as barriers to health care, the Harvard and Emory studies suggest the gap has widened, rather than narrowed, since then.
In early 2005, former U.S. Surgeon General David Satcher, MD, reported in the journal Health Affairs that 84,000 black Americans die each year because of disparities in care.
Unequal detection and treatment found
In the Emory report, researchers looked at gender and racial differences in the management of acute myocardial infarction.1 The treatment of 600,000 patients was reviewed, and researchers found that blacks — and black women, in particular — were substantially less likely to receive reperfusion therapy or coronary angiography. Over the period studied, 1994 through 2002, the gap did not narrow.
Another study, led by researchers from Harvard’s school of public health, reviewed utilization of nine major surgical procedures in elderly patients, including coronary artery bypass grafting, total hip replacement, and carotid endarterectomy.2 During the time period reviewed, 1992 through 2001, racial disparities in providing the procedures actually widened for five of them and remained unchanged for three others. Only one procedure studied indicated a narrowing of the gap.
Limited improvement lends hope
Amal N. Trivedi, MD, a research fellow at Harvard-affiliated Brigham and Women’s Hospital in Boston, led the third study published in the New England Journal of Medicine, analyzing Health Plan Employer Data and Information Set (HEDIS) measures involving 1.5 million individuals enrolled in 183 Medicare managed care plans from 1997 through 2003.3 Health plans participating in Medicare have been required to submit publicly reported data using specific HEDIS quality indicators since 1997.
"What we found was encouraging," Trivedi says. "Across all nine measures of care, care improved for all enrollees [black and white], and in seven of the nine, care became more equal between racial groups."
Disparities remain somewhat unchanged in measures of care for control of glucose and cholesterol.
The percentages of black enrollees with diabetes who had their low-density lipoprotein (LDL) levels measured rose from 61% in 1999 to 92% in 2003, a 31% gain. The percentage of black enrollees with diabetes who had their LDL levels controlled increased even more, by 43% (from 23% in 1999 to 66% in 2003). White enrollees’ rates also improved for both measures (from 9% to 2% for LDL testing and from 13% to 7% for LDL control), but the gains made by blacks narrowed their gaps.
Similarly, the percentages of black and white enrollees who were prescribed a beta-blocker within seven days of hospital discharge following a heart attack, heart bypass surgery, or angioplasty rose respectively from 64% to 93% and 76% to 94% between 1997 and 2002. This progress resulted in many more blacks and whites getting optimal care and narrowed the treatment disparity from 12 percentage points to 1 percentage point.
Blacks fell further behind whites in control of blood glucose. The proportion of black enrollees with diabetes who had their blood sugar levels controlled according to nationally recognized clinical performance standards rose only 8 percentage points (from 67% to 75%), while for whites the proportion rose 11 percentage points (from 71% to 82%).
The study of HEDIS measures did not identify factors that contributed to the improvement in equality, but Trivedi says the process of required measures and public reporting of quality likely played a big role in reducing disparity.
Trivedi says the findings "offer a measure of hope that it’s possible to reduce and eliminate disparities," but he says the two other studies on disparities that were reported at the same time as the HEDIS study include data he found "quite sobering."
"If you look at all three studies together, it’s partly encouraging news, but we need a more concerted effort among health plans, hospitals, clinicians, and policy-makers to address and eliminate these disparities," he says.
Seeking solutions to disparities
Massachusetts General Hospital and Partners HealthCare System in Boston announced in July that their collaborative effort, the Disparities Solutions Center, would pull together health plans, medical centers, and researchers to search for answers to disparities in delivery of care.
Mass General and Partners HealthCare will invest $3 million over five years to fund research and provide training for health care professionals on care inequality. The organizations plan for the center to be funded beyond the first five years by grants and contracts from other hospitals that want to participate in solving their own disparity issues.
References
- Vaccarino V, Rathore SS, Wenger NK, et al. Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002. N Engl J Med 2005; 353:671-682.
- Jha AK, Fisher ES, Li Z, et al. Racial trends in the use of major procedures among the elderly. N Engl J Med 2005; 353: 683-691.
- Trivedi AN, Zaslavsky AM, Schneider EC, et al. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med 2005; 353:692-700.
Source
- Amal N. Trivedi, MD, research fellow, Brigham and Women’s Hospital, Boston. E-mail: [email protected].
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