Study details gap in death rate by race; health care disparities blamed

As the American Medical Association, National Medical Assn. and more than 30 other organizations prepare for a Jan. 31, 2005, launch of a commission to attack the problem of health care disparities among racial and ethnic minorities, a new study underscores the dire need for such an effort.

According to the report, published in the December issue of the American Journal of Public Health, resolving racial disparities in health care could save fives times as many lives as the number saved by technological advances made in improving drugs, devices and medical procedures. Comparing mortality data of whites and African-Americans between 1991 and 2000, the researchers -- including a former U.S. surgeon general -- said they hope to highlight the impact of these disparities, as well as the effect of health care research priorities, which they say favor expensive "incremental improvements" in treatments over reducing the disparities in which these treatments are applied.

AMA President John C. Nelson, MD, MPH, said his first reaction after reading the study was "Wow."

"The magnitude is amazing," said Dr. Nelson, a Salt Lake City-based obstetrician-gynecologist who has pledged to make resolving health care disparities a priority of his presidency. "This adds tremendous fuel to our fire and will help us do our job to make our colleagues aware that this is a real problem."

Dr. Nelson said reducing disparities encompasses the AMA traditions of science, caring and ethics. "If we know something is a problem, we have to do something about it," he said. "Do we have a systematic bias that allows it to occur? If so, we have to find out what it is and change it."

Researchers hope to raise awareness

The researchers calculated that technological medical advances averted 176,633 deaths between 1991 and 2000, while eliminating racial health care disparities could have averted 886,202 deaths.

"It's hoped that this article will draw attention to the importance of the need to continue investment in [disparity-reduction] programs and prevention research," said report co-author David Satcher, MD, PhD, director of the National Center for Primary Care at the Morehouse School of Medicine in Atlanta and U.S. surgeon general from 1998 to 2002.

"There are a lot of issues here, but the idea is to get people sensitized and aware of the impact of health care disparities," he said.

For example, Dr. Satcher said the issue of Medicare reimbursement obstacles and their impact on disparities is an issue health care policy-makers need to take note of.

"A problem now is that people on the front lines are getting punished for taking care of the poor because they have problems getting reimbursement," Dr. Satcher said, adding that this study helps define the impact of this policy-related problem.

To determine the number of African-American deaths attributable to higher mortality rates, Dr. Satcher and colleagues used an "indirect standardization" of mortality rates with African-Americans used as a reference population. For each year, the Caucasian age-specific mortality rate, by gender, was multiplied by the population of African-Americans in the corresponding age groups, the report stated. Then researchers divided the total calculated deaths by the population of African-Americans to arrive at a gender-specific mortality rate. This "hypothetical crude mortality rate" was subtracted from the actual African-American crude mortality rate and multiplied by the total population of African-Americans to estimate avertable deaths, the report stated. Details can be found online (link).

Declines in age-adjusted mortality rates were used to determine the benefit of medical advances. Although lead author Steven H. Woolf, MD, MPH, described this as a "back-of-the-envelope calculation," he was confident that any refinements in the data would not significantly alter the direction of their findings.

"Policy-makers shouldn't wait around for more refined calculations," said Dr. Woolf, executive vice president for policy development of Partners for Prevention, a nonprofit health policy group, and a professor and director of research at the Dept. of Family Practice at Virginia Commonwealth University. "The actual ratio might turn out to be 3-to-1, 4-to-1 or 6-to-1, but the bottom line is that the public health benefits of removing disparities are more substantial than the incremental improvements we make in treatments."

Citing his belief in the rigorous peer review process at the American Journal of Public Health, Dr. Nelson said he was confident in the researchers' statistical analysis.

Commission's mission defined

To do its part, the NMA/AMA-led Commission to End Health Care Disparities will work to promote better research, clinical services, medical work-force diversity and awareness of disparity issues, said Arthur B. Elster, MD, the AMA's director of medicine and public health.

"Many physicians still view health care disparities as a socioeconomic issue," Dr. Elster said. "But even if you account for socioeconomic factors, the disparities persist."

Dr. Satcher noted the important part primary care physicians play in efforts to reduce disparities.

"Primary care physicians have a major role to play because we're on the front lines and we have to make sure that patients -- regardless of race and ethnicity -- get quality care," Dr. Satcher said.

It's estimated that the pharmaceutical industry spends an average of $800 million on developing new drugs, Dr. Woolf noted, and the National Institutes of Health has an annual budget of almost $28 billion to carry out its mission "to acquire new knowledge to help prevent, detect, diagnose, and treat disease and disability." In comparison, the agency which investigates health care disparities -- the Agency for Healthcare Research & Quality -- gets about $319 million.

"What our research is suggesting is that this is not going to produce the best health outcomes and that we would save many more lives by adjusting our priorities," he said.