Quality of care nearly equal if access is equal

Once patients are in the exam room, race, income and insurance status make little difference in the quality of care patients receive from their physicians, with clinically recommended care being delivered only 54.9% of the time no matter whom the person is, according to a recent study.

Steven M. Asch, MD, MPH, a Los Angeles internist and lead author of the study that appeared in the March 16 New England Journal of Medicine, said there's no question enormous disparities exist in the U.S. health care system between black and white, insured and uninsured, rich and poor. But by only studying the records of patients who had seen a physician in the previous two years, researchers were able to exclude the access-to-care issues that so often confound other studies and focus on the quality of care patients of different backgrounds receive, Dr. Asch said.

"The first step in the health care process is getting in to see the doctor. Once you're in the door, it appears those things are less important than whether you get basic bread-and-butter medical care," he said. "Once in the door, it seems like we're all in the same boat and we get approximately the same level of recommended care."

Dr. Asch and his co-authors studied nearly 7,000 patients' medical records covering a four-year period.

It is the third study stemming from a RAND Health examination of the care recommended to patients in 12 cities between 1996 and 2000. The first, published in 2003, established that across 439 quality indicators developed by a panel of medical society experts for 30 acute and chronic conditions ranging from asthma to urinary tract infections, patients only received recommended care a little more than half the time. A follow-up study examined the same data to determine that where patients lived had no effect on the quality of care received.

Disproving disparities?

Some saw the latest study as evidence the focus on racial bias in medicine is misguided.

"If there is differential treatment, it's not because a doctor is saying, 'You're a black patient or a white patient and I'll treat you differently,' " said Jonathan Klick, a law professor at Florida State University and co-author of The Health Disparities Myth, a monograph published in January by the conservative think tank American Enterprise Institute. "There are larger problems with access to high-quality care. If you address those problems, the chances are you'll make headway on disparities."

Though the study's findings might appear to contradict more than a decade of research on racial and ethnic health disparities, other experts said big gaps exist in access to care, patient compliance and health outcomes.

"If we're going to sort things and ask why are there disparities in care in America, we'd say access is a big, big issue," said Ernest Moy, MD, MPH, senior service fellow at the Agency for Healthcare Research and Quality and lead author of its 2005 report on disparities. "What happens to patients before they get into care and compliance after care are also very important. But when it comes to the technical aspects of care delivered, the differences are pretty small.

"This study is unique in that it really focuses on what's happening when the physician is there with the patient," Dr. Moy added. "But it misses all the other stuff that gets tracked." For example, research has shown blacks are less likely than whites with the same diagnosis to receive high-cost surgical procedures.

The RAND study also focuses more on process-based measures than outcomes, said Hoangmai H. Pham, MD, MPH, a senior health researcher at the Center for Studying Health System Change, a nonpartisan research organization.

"If I'm a patient, I want to know what quality measures are important in terms of the ultimate outcome: death," Dr. Pham said. "At the end of the day, we know that black patients have higher mortality than white patients, and we know that poor people die younger than rich people."

The AHRQ report on disparities, for example, found that blacks were 10 times more likely than whites to develop AIDS, and poor patients were 2.3 times more likely than rich patients to have trouble getting illness or injury care as soon as they wanted.

"This [RAND] study, while important, does not in any way 'disprove' disparities," said Michael W. Painter, MD, a senior program officer at the Robert Wood Johnson Foundation, which paid for the study. "This study looked at process, not outcome."

The RAND study might not disprove disparities, but it might afford doctors a chance to re-examine strategies that can work across the board, said Bruce Bagley, MD, director of quality improvement at the American Academy of Family Physicians.

"The differences in the [RAND] numbers are hardly worth talking about when they're all bad," Dr. Bagley said. "Systematic and evidence-based medical care measured for performance will help all groups. I don't care if you're working in an Indian clinic, a private office or a community health clinic."