Surgery, chronic care are worst in racial health gap

More than 600 peer-reviewed studies in the last two decades have documented the black-white disparity in health care, and the results have spurred politicians, bureaucrats and doctors into a number of efforts aimed at eliminating or at least narrowing the gap.

Three new studies published in the Aug. 18 New England Journal of Medicine attempted to track data over time to see how these efforts have panned out. The results: Although black-white disparities narrowed for some areas of relatively simple care, when it comes to surgical treatments and care of chronic conditions, the gaps have remained and in some cases actually have widened.

"The reality is that on many grounds, we don't see much changing," said Ashish K. Jha, MD, MPH, lead author of one of the studies and a professor of medicine at the Harvard School of Public Health. "The efforts we've made in the past have not been successful."

Dr. Jha's study measured how often black and white Medicare beneficiaries with the same diagnosis received one of nine high-cost surgical procedures between 1992 and 2001 and concluded that disparities widened for five, narrowed for one and went unchanged for three.

Dr. Jha and his co-authors also studied the rates of coronary artery bypass grafting, carotid endarterectomy and total hip replacement in 158 hospital-referral regions and found that although disparities narrowed in 22 of the regions, the gaps widened in 42 and were unchanged in the rest.

"We found that a given region might improve on its hip replacement rates, but the other rates seemed to widen," Dr. Jha said. "There was no consistent trend toward improvement, and in no area did the gap for procedures go away."

Gaps for aspirin, beta-blockers close

Another study looked at race and gender disparities in the treatment of heart disease from 1994 to 2002 and found no disparities in the use of aspirin and beta-blockers but did find gaps in rates of reperfusion therapy, coronary angiography and in-hospital death, with no signs of narrowing.

"There are fewer risks for [aspirin and beta-blockers], so it's easier to administer them to pretty much everybody," said Viola Vaccarino, MD, PhD, lead author of the study. "Even if the diagnosis is not completely clear, it's OK to do it anyway."

She said that might not be the case with other, riskier treatments and that because women and blacks tend to complain of different symptoms than do white men, it might not be immediately clear to physicians that the patients are in fact having a heart attack.

"Aspirin and beta-blockers are really cheap prevention," added Dr. Vaccarino, associate professor of medicine at Emory School of Medicine in Atlanta. "For the other procedures, cost issues might arise for certain groups."

The third study examined black-white disparities among Medicare beneficiaries on nine Health Plan Employer Data and Information Set measures such as breast-cancer screening, diabetes and cardiovascular care from 1997 to 2003.

Disparities narrowed for seven of the nine measures, but when it came to controlling both glucose and cholesterol levels, the disparities actually widened from 4% to 7% and from 14% to 17%, respectively.

"It's relatively uncomplicated to do a test or prescribe the right medicine," said Amal N. Trivedi, MD, MPH, a Harvard Medical School research fellow and the study's lead author. "It's much more complicated to reduce glucose or cholesterol levels. That requires having a regular relationship with a doctor, and it means the patient being able to afford the medicine."

An editorial accompanying the studies called on health plans and health systems to collect racial and ethnic information to better understand where disparities exist and how to eliminate them.

John C. Nelson, MD, MPH, immediate past president of the American Medical Association, also believes better data should be collected. "In the politically correct world, we didn't talk about race, but all that does is mask the problem.

"We can't force people to disclose their race if they choose not to, but it would be helpful to us so we could do a better job," he said.