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Racial disparities exist in long-term mortality among elderly blacks and whites. Black patients are less likely than white patients to undergo a potentially life-saving procedure, which may explain in part their lower rate of survival following cardiac arrest, according to a recent study that was supported in part by the Agency for Healthcare Research and Quality. Similarly, even though blacks have more emergency visits and hospitalizations for scleroderma than whites, suggesting they have more severe disease, they are referred less often to specialized centers for treatment, according to a second AHRQ-supported study. A third AHRQ-supported study confirms that blacks and other minorities have much more difficulty than whites in accessing care, and they use less care. The three studies are described here.
Groeneveld, P.W., Heidenreich, P.A., and Garber, A.M. (2003, July). "Racial disparity in cardiac procedures and mortality among long-term survivors of cardiac arrest." (NRSA training grant T32 HS00028). Circulation 108, pp. 286-291.
Implantable cardioverter-defibrillators (ICDs)—devices that automatically shock the heart to convert irregular, life-threatening heartbeat to normal rhythm—can improve survival after cardiac arrest. In this study, the researchers examined Medicare records to assess whether there are racial disparities in the use of life-saving procedures after cardiac arrest, and whether differences in procedure rates may contribute to black-white differences in long-term mortality.
The researchers examined data on 5,948 Medicare beneficiaries (5,429 white and 519 black) aged 66 or older who survived to hospital discharge between 1990 and 1999 after admission for cardiac arrest. They developed a
model to identify predictors of death following cardiac arrest, including demographic and clinical factors and receipt of cardiac procedures, and followed the patients for a median of 4.8 years. By December 1999, 50 percent of patients had died.
After stratifying patients by race, ICDs reduced the mortality ratio by half for both white and black patients (0.53 and 0.50, respectively). However, blacks were only half as likely as whites to receive either an ICD or a coronary revascularization procedure (angioplasty or bypass surgery).
Nietert, P.J., and Silver, R.M. (2003). "Patterns of hospital admissions and emergency room visits among patients with scleroderma in South Carolina, USA." (AHRQ grant HS10871). Journal of Rheumatology 30(6), pp. 1238-1243.
Scleroderma is a disease characterized by degeneration of the connective tissue of the skin, lungs, and internal organs, especially the esophagus and kidneys. The disease can progress from thickening of skin on the face and fingers, to joint deformity and pain, and finally to kidney and heart failure from damaged organs. This study found that blacks and women are more affected by the disease than whites and men. In addition, blacks visit the hospital and emergency department (ED) for scleroderma crises more than whites, suggesting more severe disease, but they are less likely to be referred to a specialized scleroderma center.
These findings highlight a potential racial disparity in access to optimal health care services for scleroderma patients, conclude the investigators. They analyzed data on all South Carolina hospitalizations from 1996 to 2000 to identify patients hospitalized for scleroderma and used the 2000 U.S. Census data to determine population incidence rates across race, sex, and age groups. Of the 785 scleroderma patients identified, blacks had a 66 percent higher rate of hospitalization for scleroderma than whites and a 78 percent higher rate of ED use. Blacks were more likely than whites or patients of other races to have hospital admissions classified as emergencies.
Even after adjusting for sex, age, income, insurance status, and other factors, blacks were 60 percent less likely than whites to receive inpatient treatment at the Medical University of South Carolina (MUSC), a major referral center for patients with scleroderma in the Southeastern United States. The researchers found similar results when they compared other minority patients with white scleroderma patients. Males and younger patients also were more likely to be referred to MUSC than women and older patients.
Lurie, N., Zhan, C., Sangl, J., and others (2003, July). "Variation in racial and ethnic differences in consumer assessments of health care." American Journal of Managed Care 9, pp. 502-509.
Surveys of how white and minority consumers assess the health care they receive revealed that minority patients have much larger problems with access to care and less use of health care than whites. These differences suggest compromised quality of health care for minorities and opportunities for improving care quality, conclude AHRQ researchers Chunliu Zhan, M.D., Ph.D., Judith Sangl, Sc.D., and Arlene S. Bierman, M.D., M.S. Along with their colleagues from RAND and the Centers for Medicare & Medicaid Services, they analyzed data from 160,694 responses from members of 307 commercial health plans and 177,489 responses from Medicare beneficiaries in 308 Medicare+Choice managed care plans to the 1999 Consumer Assessment of Health Plans Study (CAHPS®) survey.
The researchers compared global care and composite ratings as well as access to and use of care as reported by whites, blacks, Hispanics, and Asians. Blacks rated their care and their doctors higher than whites (82.35 and 83.94 vs. 80.42 and 81.59, respectively), while Asians rated their care and doctors lower than whites (78.52 vs. 80.42 and 80.29 vs. 81.59). Blacks reported better experience with care than whites (perhaps due to lower expectations), but Hispanics and Asians reported worse experiences.
All minority groups reported more problems with access to care and less use of health care than whites. Whites were consistently more likely than others to report having any medical visits, having a personal doctor, seeing a specialist, and seeing a specialist when they felt it was necessary. These racial differences in assessment of access and use varied greatly from plan to plan, suggesting that some plans have more serious disparities than others, note the researchers. They call for an in-depth study of "best practice" plans to eliminate disparities in care.
Reprints (AHRQ Publication No. 03-R063) are available from the AHRQ Publications Clearinghouse.
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