Health disparities: Are we making progress?

The medical community received a wake-up call in 2002 regarding the care given to patients across races and ethnicities. The Institute of Medicine report, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care," found significant variation by race, even when insurance status, income, age and severity of conditions were comparable.

Four years have passed. It's time to assess progress. But has any been made? Perhaps some, say those on the front lines.

"We've done a pretty good job of building awareness," said Ron Davis, MD, AMA's president-elect. And eliminating health disparities has been taken on as an overarching goal for the national health agenda, Healthy People 2010, he noted.

But there is still a long way to go. Now that the problems are gaining recognition, attention is shifting to resolving them, and many experts are focused on this task. Each of the following was asked whether, in recent years, they have seen progress in eliminating health disparities in their specialties.

Joseph Betancourt, MD, MPH, director of the Disparities Solutions Center at Massachusetts General Hospital in Boston, assessed the big picture:

"I think there has been progress made. At the grassroots level, there has been a lot of progress. Hospital task forces or statewide task forces have been set up to better examine the area of disparities.

"The field is in the monitoring phase now. A lot of the research is national, but I think people are interested in knowing what's happening in their practice or hospital.

"On the state level, we've seen a couple of different things indicative of progress. In Massachusetts, our health care reform had several provisions that focused on the issue of health disparities on the legislative side. The governor is to name a council that will oversee all state efforts to address disparities. The Legislature has also mandated the collection of race and ethnicity data at all hospitals and charged the state with developing a pay-for-performance program to address disparities. This is to be funded with Medicaid dollars and is targeted at hospitals.

"Several states, in particular New Jersey, California, and Washington, have mandated cultural competence continuing medical education for physicians as a condition of licensure."

Rita J. Louard, MD, director of the Clinical Diabetes Program at Montefiore Medical Center in New York, addressed diabetes care:

"I'm not sure that we have necessarily made progress. We probably haven't lost ground, but I'm not quite sure we have actually gained. We're just not doing a good job for anybody.

"Now, do African-Americans, Asian-Americans or Latinos have higher rates of diabetes? Yes. Can we improve the care we give them? Yes. But we can improve the care we give everybody with diabetes.

"I think there are many areas we can work on. Part of it is patient education. There is a fatalistic feeling among all groups that, 'I have this disease, and bad things are going to happen.' I don't think that is necessarily true. When we look at many of the studies that have tried to determine the impact of intensive management, regardless of the group you are in, intensive management not only improves outcomes, but people feel better.

"We need to keep in mind that compared with even 10 years ago, we have many more options for treatment. And regardless of the wonderful medication options, the foundation for prevention and treatment is lifestyle modification. We have to stress that for all people."

Lovell A. Jones, PhD, director of the Center for Research on Minority Health at the University of Texas' MD Anderson Cancer Center in Houston, spoke about cancer and minority populations:

"Although cancer screening data indicate there is very little difference between blacks and whites in terms of screening, when you ask the question about repetitive screenings, the disparities start to show up.

"Given the idea that, for instance, breast cancer occurs earlier in African-American women -- and there are data now to support that it is biologically more aggressive -- if you don't have comparative screenings you may miss something, and you end up with a disease that is at a later stage. The issue may not be related to access but to the biology of the disease and how often that person went in for screening.

"Also, what was surprising to me was that among Hispanic women, the breast cancer rates for those younger than age 50 were close to that of African-Americans.

"The data on prostate cancer follow the same trend among African-American men. It occurs earlier and seems to be more aggressive. There are now data coming out of Africa that indicate there may be some genetic component. In the Western African population, the disease is occurring earlier and is more aggressive."

Elizabeth Ofili, MD, MPH, professor of medicine and chief of cardiology at Morehouse School of Medicine in Atlanta, on cardiovascular care:

"I tend to be pessimistic mostly because there is just so much we are leaving on the table in terms of recognition and opportunities for preventive interventions. When we look at the traditional risk factors -- be it high blood pressure, high cholesterol, diabetes, smoking -- there is still a significant lack, when you look at African-Americans versus whites or even Hispanic-Americans, in terms of diagnosis and access to effective treatment for these conditions. And when you look at the ones that are easily measured, like blood pressure and cholesterol, rates of control are still much lower for African-Americans and for Hispanic-Americans as well.

"Why is that, you ask? The answer comes out in multiple dimensions. The first dimension is burden of disease, and that is probably, quite frankly, tied to socioeconomic factors. There is, for instance, a higher prevalence of high blood pressure. When people are diagnosed with high blood pressure, certainly if they are African-Americans, they are more likely to have complications existing already due to delay in the diagnosis and issues around consistent access to primary care. Fewer African-Americans have a primary care doctor they go to on a regular basis. And that's one challenge.

"We've shown it is possible to get more and more of these African-American patients treated to what we call goal. But it takes a series of efforts and strategies. You can't just take a prescription and hand it to them. You have to spend a little bit of extra time talking to them about lifestyles and strategies with the medicine and the combinations of medicines that will be needed. Also, teaching them to monitor their own health: When the patient is involved in their own care they get better outcomes; we've shown that."

Sergio Aguilar-Gaxiola, MD, PhD, chair of the National Mental Health Assn.'s board of directors and founding director of the University of California, Davis Center for Reducing Health Disparities, on mental health disparities:

"Mental health has been the ugly duckling traditionally. Data about mental disorders indicate we ought to be paying attention because they are not only very frequent, but they are very costly. Studies by the World Health Organization that look at the level of disability that health conditions produce showed that the one on top is depression. It is amazing when one thinks about the day-to-day impact of other things that cause disability, like terminal cancer or paralysis, that depression comes out on top.

"So, can we define depression and measure it reliably? Yes. Is depression an important public health problem? Definitely yes. ... Is there efficacious treatment? Yes. Medications and cognitive behavioral therapy when delivered appropriately can help people get better. Unfortunately, the data we have tell us that major depression isn't likely to be detected. And when detected, the treatments aren't given at the right dosages or for the needed duration."