New evidence finds disparities aren't usually due to bias

But researchers say cultural barriers should not be ignored as physicians look to improve the health care system.

By Kevin B. O’Reilly — Posted Aug. 6, 2007

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Two recently released studies added to the increasing weight of evidence suggesting that health care disparities are due mostly to where minorities receive treatment rather than to racism or cultural insensitivity.

An Archives of Internal Medicine study examined how 123 teaching hospitals scored on Hospital Quality Alliance measures in caring for more than 320,000 patients. After adjusting for where minority patients were treated, the researchers found racial and ethnic disparities were vastly reduced or even eliminated. And a report released by the Commonwealth Fund, a health care policy nonprofit, surveyed nearly 3,000 patients and determined that those whose physicians provided a medical home received more equitable treatment.

"These data add to a briskly growing literature showing that the most profound effects on health differences by race are due to socioeconomic factors, not bias on the part of physicians," said Sally Satel, MD, co-author of The Health Disparities Myth: Diagnosing the Treatment Gap, published in 2006 by the conservative American Enterprise Institute.

An editorial accompanying the June 25 Archives study came to a similar conclusion. The article's findings "demonstrate that most disparities in the quality of hospital care depend on where you seek care, not on your race [or] ethnicity," wrote Memphis internists James E. Bailey, MD, MPH, and Laura R. Sprabery, MD.

They added that because care for minorities is heavily concentrated in underfunded urban hospitals, "the most pressing inequalities in health care may be driven by economics."

When researchers analyzed the so-called hospital effect, racial disparities lessened significantly on metrics for heart attack, congestive heart failure and pneumonia care. The most striking example was on discharge instructions for congestive heart failure, where a 10-percentage-point difference disappeared after controlling for the site of treatment.

Lead author Romana Hasnain-Wynia, PhD, said her study does not mean physicians and hospitals should focus only on generic quality improvement and ignore cultural barriers that can affect minorities' care.

"It may well be that organizations are very focused on making sure everyone receives the highest quality of care," said Dr. Hasnain-Wynia, vice president of research at the American Hospital Assn.'s Health Research & Educational Trust. "But if we do not focus some of our resources toward understanding the patients we serve -- their language needs, their cultural values, beliefs and behaviors -- then we'll be missing the boat in terms of improving quality for everyone."

Ernie Moy, MD, MPH, agreed.

"Minorities going to poorer-performing hospitals is an important contributor [to racial gaps in care], but it doesn't totally explain away all the disparities," said Dr. Moy, lead author of the Dept. of Health and Human Services' Agency for Healthcare Research and Quality's most recent national disparities report. "For some reason, and we don't know why, people of color are not getting the same care as people who are white. There, presumably, it's not an issue of quality improvement in general."

Medical homes offer promise

Meanwhile, the Commonwealth Fund report, released in late June, suggests that medical homes nearly eliminate disparities. In the last few years, organized medicine groups representing pediatricians, family physicians and internists have endorsed the medical home concept, which emphasizes physician continuity, quality improvement, open scheduling and expanded hours.

Researchers asked patients questions aimed at defining the "medical homeness" of the care they received, such as whether they could contact physicians by telephone, get help at night or on weekends, and whether offices seemed to run on time. Then, patients were asked about what preventive care and counseling they had received in the last two years.

Unsurprisingly, insured patients were more likely to get the right care than were uninsured patients. However, not only did all patients with a medical home do better than insured patients whose doctors did not provide a medical home, but gaps between whites and blacks and Hispanics disappeared, according to the report.

Lead author Anne C. Beal, MD, MPH, said disparities research should focus not only on diagnosing where gaps exist but on finding solutions about how to address them.

"That's where this study takes things a little bit further," said Dr. Beal, who specializes in research on underserved populations for the Commonwealth Fund. "When we found high-performing places that are medical homes, that's where we found there were no disparities."

Mohammad N. Akhter, MD, MPH, executive director of the National Medical Assn., agreed that medical homes are a promising avenue to pursue in the effort to reduce racial care gaps. He said the new studies show "there is no silver bullet" to solve the problem of health care disparities.

Back to top


Closing the racial gap

Physician practices that embody the principles of a medical home deliver higher quality and more equitable treatment, according to a new survey or nearly 3,000 patients. One measure of quality, shown below, was how likely patients were to receive reminders about preventive care visits.

Patients receiving visit reminders:

Care type White Black Hispanic
Medical home 66% 64% 64%
Regular care source, but not medical home 54% 48% 49%
No regular source of care/ED 23% 25% 21%

Source: "Closing the Divide: How Medical Homes Promote Equity in Health Care: Results From the Commonwealth Fund 2006 Health Care Quality Survey," June 27, by Anne C. Beal, MD, MPH, et al.

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn