Politics charged in disparities report

Trying to stay above the fray, a former AMA president, Alan Nelson, MD, says health care disparities exist and must be confronted.

By Andis Robeznieks — Posted Feb. 2, 2004

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Democrats claim that the Bush Administration manipulates science for political purposes, administration officials deny it, and a past president of the American Medical Association is caught in the middle.

The controversy involves the recent U.S. Agency for Healthcare Research and Quality Report on health care disparities. U.S. Rep. Henry Waxman (D, Calif.) charges that the report's executive summary was watered down, with serious problems downplayed and minor successes overemphasized.

Waxman released an analysis comparing the final version of the report's executive summary with a draft completed in June, showing that 28 mentions of the word "disparity" were removed from the final version; a conclusion stating that health care disparities "are national problems" was deleted; and a passage listing disparities relating to cancer, HIV and cardiac care was replaced with a reference to low use of cholesterol tests.

AHRQ Director Carolyn Clancy, MD, however, said that although changes were made to the executive summary, none of the data included in the report were "changed, altered or modified whatsoever." She added that the report included information on 300 different disparity measures, so "there's no way an executive summary could cover it all."

Waxman's report quotes remarks by Alan Nelson, MD, a former AMA president, who also chaired the Institute of Medicine committee that produced the 2002 report "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care."

Dr. Nelson, who served on the committee as an individual, agreed that the IOM report was "more forceful" than the AHRQ report and that the early draft used stronger language than the final version released this past December, but he wouldn't speculate as to the motives for the changes.

"One of their points is that IOM's report was more aggressive, and I think that's true," said Dr. Nelson, AMA president in 1989-90.

But Dr. Nelson, a former Salt Lake City-based internist-endocrinologist who now lives in Fairfax, Va., said he was pleased that Congress and the Bush administration were interested in the issue, and he downplayed the significance of the controversy.

"To me, this is not important in the big scheme of things about what medicine is doing to confront these disparities," he said. "The December report casts the situation in a more favorable light than the June draft, but it doesn't trivialize the problem. It still says, 'This is a problem we need to confront.' There's no question in my mind that HHS [Health and Human Services] and AHRQ regard disparities as an important problem.

"The science that exists is undisputable: Disparities exist and must be confronted," he added. "The first step, in my view, is to make everyone aware that there's a problem."

Going soft?

Waxman's analysis quotes Dr. Nelson's 2002 remarks calling for energy to be focused on development and implementation of strategies to remove disparities. The congressman worries that the soft approach taken in the AHRQ report's executive summary indicates a step back to debating whether disparities exist.

"This report should have been based on science and not political spin," Waxman said in an e-mail to AMNews. "The truth about health care disparities may not be encouraging, but the job of science is not to put on a happy face. It's to develop evidence for the creation of sound policy. The tragedy of this episode is that an honest report on health disparities could have been a major spur to Congress."

Dr. Nelson said groups such as the AMA Minority Affairs Consortium and the National Medical Assn. "have really stepped up to the plate in reducing disparities." He added that, just because there hasn't been legislation, doesn't mean that progress hasn't been made or that work isn't being done.

Dr. Clancy confirmed that the subject, but not necessarily the report, appears to be generating a lot of activity.

She explained that the disparities report had received the usual amount of attention given to a government document, but she was "stunned and impressed" by the amount of Internet traffic to the "Quality Tools" section of the AHRQ Web site devoted to addressing disparity problems.

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Disparate disparities

U.S. Rep. Henry Waxman (D, Calif.) cites changes made to the executive summary of the National Healthcare Disparities Report as the latest example of the Bush administration's distortion of science to promote its ideological agenda. Here are some examples of the differences between disparities listed in the draft and in the final version.

Draft version

  • Minorities are more likely to be diagnosed with late-stage breast cancer and colorectal cancer when compared with whites.
  • When hospitalized with myocardial infarction, Hispanics are less likely to receive optimal care.
  • The use of physical restraints in nursing homes is higher among Hispanics and Asian/Pacific Islanders when compared with non-Hispanic whites.

Final version

  • Hispanics and American Indians or Alaskan Natives are less likely to have their cholesterol checked.
  • Rates of admission for conditions that are usually treatable with ambulatory care are generally higher for people who live in low-income areas.

Source: "A Case Study in Politics and Science: Changes to the National Healthcare Disparities Report," investigation by the minority staff of the U.S. House Committee on Government Reform

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External links

"A Case Study in Politics and Science: Changes to the National Healthcare Disparities Report," U.S. House Committee on Government Reform minority staff report, in pdf (link)

AHRQ National Healthcare Disparities Report (link)

U.S. Agency for Healthcare Research and Quality's Quality Tools clearinghouse (link)

AMA Minority Affairs Consortium (link)

"The Right to Equal Treatment: Racial and Ethnic Disparities in the Quality of Care," Harvard Health Policy Review, Fall 2003, in pdf (link)

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