Some Care Disparities Narrow Though Inequalities Persist

Three independent groups of researchers who set out to find whether the racial gap in health care is narrowing have detected some limited signs of improvement.

The trio of studies represents the first major analyses of disparity trends over the last decade. By now, the researchers expected, the numbers would begin to reflect changes based on greater awareness from the hundreds of studies, several major reports, widespread media attention, and acknowledgement of the problem by the federal government.

The new findings suggest that more targeted interventions and systemic changes will be necessary to close the gaps in treatment and outcomes for African Americans. The papers were published in the Aug. 18 New England Journal of Medicine by researchers from HMS, HSPH, Brigham and Women’s Hospital, and other universities.

“Public reporting and general efforts to improve the quality of care will take us part of the way toward eliminating disparities, but focused programs will be needed to eliminate racial disparities completely,” said John Ayanian, HMS associate professor of medicine at BWH and of health care policy and senior author of the study that found some improvements.

Many policy experts see a clear advantage in piggybacking on efforts already under way to improve the quality of care for everyone. “Any variation in appropriate care is really a quality defect,” said Amal Trivedi, an HMS research fellow in medicine at BWH who led the study. “For most measures, the quality of care remains suboptimal for both blacks and whites.”

Photos by Steve Gilbert

Upgrading the quality of care for everyone helped eliminate some racial disparities in managed care Medicare plans, according to a study by Amal Trivedi (top) and co-authors (bottom, from right) Eric Schneider, John Ayanian, and Alan Zaslavsky. A companion study led by Ashish Jha (middle) found no consistent narrowing of disparities for major surgeries in the main Medicare population.

About 12 to 16 percent of Medicare beneficiaries are enrolled in managed care plans, and they have tended to be healthier than the general senior population, Trivedi said. Since 1997, the U.S. government required the plans to publicly report performance measures.

Along with the overall improvement on most measures, the racial disparities narrowed for seven out of the nine indicators the researchers evaluated. The study accounted for differences in age and socioeconomic status.

In five of those markers, the disparity between blacks and whites narrowed to 2 percent or less: annual mammograms for women; beta-blocker prescriptions for people who have had heart attacks; and annual eye exams, blood sugar testing, and LDL cholesterol tests for people with diabetes.

The two important indicators that showed no improvement reflect measures designed to slow progression of chronic disease—controlling blood sugar in people with diabetes and LDL cholesterol in people with cardiovascular disease.

“The study supports the hypothesis that broad improvements in quality of care may be associated with reductions in racial disparities, but we may need more tailored interventions specifically directed toward black patients or their providers to fully eliminate disparities in the future,” Trivedi said.

“This tells us things can change,” said Nicole Lurie, a health disparities researcher at RAND in Arlington, Va., who wrote an accompanying editorial titled “Health Disparities—Less Talk, More Action,” which focuses on the need to move beyond documenting disparities and begin testing more interventions to fix the problem.

Unequal Care in Surgery
A second study examining major surgery rates among the 29 million seniors enrolled in fee-for-service Medicare tells a less encouraging story.

“We set out to find where local regions had narrowed or eliminated gaps between blacks and whites, so we could learn from them and extrapolate and apply the lessons to the rest of the country,” said first author Ashish Jha, HSPH assistant professor of health policy and HMS assistant professor of medicine at BWH.

Instead, he said, “we found convincing evidence that blacks and whites continue to receive different care, and nothing we’ve done in the last decade or two has equalized care.”

Jha and his co-authors first examined national rates of nine major surgical procedures previously shown to be performed at lower rates in blacks than in whites. Although the overall rates of surgery increased from 1992 to 2001, the difference between rates for whites and blacks narrowed only for one of these procedures in men, abdominal aortic aneurysm, and one in women, angioplasty. The gap widened for five procedures—total hip replacement, total knee replacement, back surgery, appendectomy, heart valve replacement—and remained unchanged for three—angioplasty for men and abdominal aortic aneurysm for women, coronary artery bypass graft (CABG) surgery, and carotid endarterectomy.

“Public reporting and general efforts to improve the quality of care will take us part of the way toward eliminating disparities, but focused programs will be needed to eliminate racial disparities completely.”

The team examined three procedures in more detail, using hospital-referral regions performing enough of each surgery for statistical power. The regions varied widely. In each region, whites had a higher surgery rate, but blacks in a few regions had higher rates of surgery than whites in other regions. And regions where more whites were wheeled into the operating room also put blacks under the knife more often.

For total hip replacements, the white–black gap widened significantly in five of 20 regions. Most regions showed a widening gap for carotid endarterectomies. Though an even greater number showed a narrowing in CABG surgery, the researchers interpret this finding as an artifact of the study. No region showed a consistent pattern of improvement, Jha said.

The study could not differentiate overuse among white patients, underuse among black patients, or some combination of the two, which previous studies have found. To close the gaps, Jha and his colleagues do not necessarily recommend more surgeries for blacks. As a matter of fact, a co-author from Dartmouth Medical School has shown in other studies that more medical care may lead to worse outcomes.

But a third study did take disease prevalence and medically appropriate treatment into ac-count and still found persistent racial differences in the use of clot--busting drugs and coronary angiography and in the rate of in-hospital deaths after heart attacks. Use of aspirin and beta-blockers, on the other hand, did not seem to vary with race and gender from 1994 to 2002.

“This was definitely a surprise,” said lead author Viola Vaccarino, associate professor of medicine at the Emory University School of Medicine in Atlanta, because there has been a lot of research on disparities in the use of treatments for cardiovascular disease.

Even so, as recently as last year, one third of cardiologists who responded to a survey agreed that “clinically similar patients receive different cardiovascular care based on what their race and ethnic background is,” observed Lurie in her editorial.

“These studies are important because they keep the issue on the front burner, but we should not have expected a lot of change in that time frame,” said Joseph Betancourt, director of the Disparities Solutions Center at Massachusetts General Hospital and HMS assistant professor of medicine. The issue of disparities did not begin to bubble up into the public and political consciousness until the 1998 Clinton initiative on race and the 2002 Institute of Medicine Report, said Betancourt, who was on the IOM committee that authored the report, “Unequal Treatment.”

“Although there was some elimination of disparities, it represents low-hanging fruit,” he said. “It definitely highlights that improvements in quality should be helpful, but there are much more challenging issues to address, such as getting rid of disparities in management of diabetes as opposed to just testing blood sugar.”

—Carol Cruzan Morton

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