Research documents disparities, but solutions remain elusive

Studies show differences in outcomes between black and white heart patients, but the process of deciding what doctors should do about it is just beginning.

By Myrle Croasdale — Posted April 4, 2005

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A series of studies and reports recently released in two health care journals provide overwhelming evidence for something on which many physicians and doctor organizations already agree: Minority patients appear to be getting worse care and having worse outcomes than white patients with the same health problems.

The challenge now is identifying the solution to disparities in care, and physicians' role in any solution.

The research, published in the March 15 issue of Circulation and the March/April issue of Health Affairs, offers various suggestions of how to improve the overall health care system on multiple levels, but the studies acknowledge that remedying the situation is not easy. One part of this complex issue is physicians and their attitudes.

The American Medical Association, the National Medical Assn., the American College of Cardiology, the Assn. of Black Cardiologists and the American Heart Assn. and others are among those working on projects geared toward reducing disparities.

But a survey on cardiologists' attitudes found that while they believed in the evidence documenting these disparities, they saw the problem as one outside of their own practices and hospitals, blaming the health care system in general along with patient compliance and a lack of health insurance.

John C. Nelson, MD, MPH, president of the American Medical Association, agrees that physicians often don't see problems in their practices.

"I think most physicians feel it's for other doctors, not for their practice," Dr. Nelson said. "There's not a doctor out there who'd say, 'I treat patients differently on race.' But the data don't say that. We need to be much more competent."

A problem of perception?

Nicole Lurie, MD, MSPH, director of the RAND Center for Population Health and Health Disparities and lead author of the study "Racial and Ethnic Disparities in Care, The Perspectives of Cardiologists" in the March 15 issue of Circulation, wrote that of 344 cardiologists surveyed, only 12% felt that disparities existed in their own hospital settings, and only 5% thought they existed within their own practice.

Dr. Lurie said one reason cardiologists might think that problems are elsewhere is that doctors tend to overestimate their own effectiveness in giving guideline-compliant care.

Past research found that physicians often overestimated how frequently they screened for cancer. Also, patients and physicians tend to see their own circumstances in a more positive light. Surveys have found that patients dislike physicians in general but like their own physician. These surveys also have shown that white, black and Hispanic patients are dissatisfied with care in general but rate their own care highly.

How well patients comply with treatment plans and whether they have health insurance do contribute to disparities in care, but possibly not to the degree that doctors think they do. Cultural barriers can interfere with compliance, researchers have found. Minorities unaccustomed to hospital settings may distrust the physicians caring for them.

Even with insurance, minority patients can be shortchanged. One researcher in the Circulation/Health Affairs project found that physicians often assumed that these patients were uninsured when, in fact, they did have insurance. The doctors then made referral decisions based on these incorrect assumptions.

Disparities remain despite gains

On one hand, racial disparities in many areas of health care are significant. Cardiac care stands out. A 2002 report by the American College of Cardiology and the Kaiser Family Foundation found strong evidence for racial disparities in the use of diagnostic cardiac procedures, coronary revascularization, thrombolytic therapy and other cardiac drug therapies, procedures and treatments.

On the other hand, areas such as flu and pneumonia have seen the gap close. A report in the March/April Health Affairs by David Williams, a professor of epidemiology and a senior scientist at the Institute for Social Research at the University of Michigan, found that although flu and pneumonia remain the seventh leading cause of death, there was virtually no difference between black and white mortality rates from the diseases in 2000. In contrast, black mortality was 70% higher than whites in 1950.

While medicine has succeeded in closing the gap for flu and pneumonia, other areas remain a challenge. A new study by former U.S. Surgeon General David Satcher, MD, PhD, in Health Affairs, estimates that the deaths of more than 83,000 black Americans a year could be prevented if the black-white mortality gap were closed.

Cardiovascular diseases alone account for more than one third of the difference in life expectancy between blacks and whites, another report says, and the Centers for Disease Control and Prevention cites the disparities in cardiovascular health as one of the most serious public health problems in the United States today.

George A. Mensah, MD, acting director of the National Center for Chronic Disease Prevention and Health Promotion, presents a strategic plan in Circulation focusing on eliminating disparities in cardiovascular health by calling for a multidisciplinary approach in all major settings of people's lives.

In kind, Dr. Satcher calls for systems changes in health care such as universal health insurance coverage, a primary care medical home for each American, proportionate representation of blacks in the health professions, and the elimination of bias in the delivery of diagnostic and therapeutic interventions.

Recently, the AMA, the NMA and the National Hispanic Medical Assn. joined to create a commission to end health care disparities, made up of leaders from physicians' organizations and more than 30 health-related groups. The ACC and the AHA are in the midst of developing quality care interventions and educating physicians on them, and the Robert Wood Johnson Foundation has started a new quality improvement initiative focused on cardiovascular care.

Robert O. Bonow, MD, past president of the AHA and chief of cardiology at Northwestern University Memorial Hospital in Chicago, said physicians need to rethink how they communicate with patients and what kinds of systems they have set up in their own practices.

"Despite hundreds of publications showing there's preventable difference in care ... only 5% of cardiologists thought it [racial disparities] might be in their own practice."

"Most physicians do the very best they can," Dr. Bonow said. "We're all very busy. We're all spread thin. You have 15 minutes with a patient. You don't have time to think of social issues all the time, if they really understand or if they have the economic wherewithal to get the meds you are prescribing."

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Counting the deaths

Who lives and who dies is one way to measure health care outcomes and racial disparities in care. The March/April issue of Health Affairs examines many aspects of race and health, but one study specifically looks at the mortality rates of blacks and whites. Researchers found:

  • There was a large reduction in death rates for blacks between 1960 and 2000, but the disparity between the higher mortality rates for blacks and lower rates for whites did not change much during those four decades.
  • In 2002, blacks had 40.5% more deaths, or 83,570 more blacks died, than would be expected if they had had the same mortality rates as whites.
  • Gender makes a difference. Black women's death rates went down over the 40 years studied, while the rate for black men rose or worsened. Black men age 45 and older experienced the biggest increase in death rates compared with whites, while black men 85 and older were the only group to have lower death rates then their white peers.

Source: "What if We Were Equal? A Comparison of the Black-White Mortality Gap in 1960 and 2000," Health Affairs, March/April

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Study at a glance

Title: "Racial and Ethnic Disparities in Care, The Perspectives of Cardiologists," Circulation, March 15,

Lead author: Nicole Lurie, MD, MSPH, a researcher with RAND Corp., a nonprofit research organization, and director of the RAND Center for Population Health and Health Disparities.

What the study found: Of the 344 cardiologists surveyed, most of whom were white and male and had graduated before 1985, more than 60% rated the strength of evidence documenting racial disparities in cardiovascular care as "strong" or "very strong," and 34% said these disparities existed throughout the health care system.

Some 69% believed patients receive different care based on whether they have insurance, and 58% said care differed by the type of insurance a patient had. But only 12% felt these disparities existed in their own hospital settings, and only 5% thought they existed among their own patients.

Physicians who were female, black or who had a large number of minority patients in their practices were more likely to report that disparities existed.

To overcome these disparities, 59% felt that increasing patients' self management skills would help, and 53% said expanding health insurance would make a difference. Fewer than 30% of cardiologists felt that increasing physician awareness or improving cultural competence of doctors or the institutions would be useful.

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Easing disparities: Cardiac care tips

Luther Clark, MD, is president of the Academy of Black Cardiologists and chief of the division of cardiovascular medicine at State University of New York Downstate Medical Center as well as chief of cardiology at Kings County Hospital Center. He treats a large number of black patients and has done research into the causes of racial disparities in cardiovascular disease. He offered his perspective on what cardiologists and primary care physicians could do better when treating black patients with heart disease.

  • Black patients having a heart attack can be difficult to diagnose quickly, and fast, aggressive treatment is critical to their survival. They often complain of discomfort in the chest and abdomen, calling it indigestion. They also commonly have other issues that make an accurate diagnosis challenging. They may be overweight, diabetic or hypertensive; have chronic kidney disease; and smoke. But they are at risk for the worst outcomes and need prompt, vigorous treatment, though often the opposite happens.
  • Next is communicating the diagnosis to the patient and family. The patient might not have a regular source of health care and have little experience with doctors. "Often this is one of the first times the patient has encountered the health care system," Dr. Clark said. "They've come into the emergency room, and all these things are happening. They've been hit with it all at once, and they don't have a trusting, comfortable relationship with the doctor who is in charge of their care."
  • Once the diagnosis is made, make sure immediate life-saving acute-care therapies and procedures are delivered, but that's just the beginning of a lifetime of change. Cardiologists should emphasize that patients ought to address related health problems, Dr. Clark said, and this is where a patient's primary care physician comes in. "Set targets for getting their blood pressure and diabetes under control. In the end, these will have a much greater impact than the acute therapies."
  • Compliance is critical. "If you don't think the patient is going to be compliant, then your own commitment to getting them treated to the appropriate goals is dampened," he said.

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External links

"Racial and Ethnic Disparities in Care, The Perspectives of Cardiologists," abstract, Circulation, March 15 (link)

"Eliminating Disparities in Cardiovascular Health," abstract, Circulation, March 15. (link)

Reports and executive summary from the AHA Conference Proceedings: Discovering the Full Spectrum of Cardiovascular Disease; Minority Health Summit 2003, Circulation, March 15 (link)

"What If We Were Equal? A Comparison Of The Black-White Mortality Gap In 1960 And 2000," abstract, Health Affairs, March/April (link)

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