New evidence finds disparities aren't usually due to bias

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.