Introduction
Racial and ethnic disparities in care have been consistently documented in the treatment and outcomes of many common clinical diseases. The 2003 Institute of Medicine (IOM) report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,” defines disparities as differences in the treatment that are not directly attributable to access-related factors, clinical needs, patient preferences, or appropriateness of intervention (Figure 3-1). The elimination of health care disparities is a high priority for the federal government and several academic organizations.
Figure 3-1
Defining differences, disparities, and discrimination in populations with equal access to healthcare. (Reproduced, with permission, from Smedley BD, Stith AY, Nelson AR. Unequal treatment. Confronting racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2002.)
Documented disparities of disease prevention and treatment include rates of vaccination, cancer screening, secondary prevention of myocardial infarction (MI), transplant surgery, curative surgery, and angioplasty. Disparities in health outcomes include cardiovascular disease, HIV/AIDS, diabetes, cancer, asthma, pregnancy outcomes, mental health, and hospitalization.
| Conditions Where Minorities Documented with Greater Rates Compared to Whites |
|---|
Cardiovascular disease:
|
| Incidence and mortality from HIV |
Type 2 diabetes:
|
Malignancy:
|
Pregnancy outcomes:
|
| End-stage renal disease |
| Preventable hospitalizations |
| Conditions Where Minorities Documented with Lower Rates Compared with Whites |
Cardiovascular procedures:
|
| Adult vaccinations |
| Solid organ transplantations |
| Secondary prevention for myocardial infarction |
| Curative surgery for lung cancer |
| Inadequate hemodialysis |
| Renal transplantation |
| Receipt of recommended care for acute myocardial infarction |
| Receipt of recommended care for pneumonia |
| Receipt of recommended care for congestive heart failure |
| Receipt of recommended care for type 2 diabetes |
| Satisfaction with hospital care |
| Age-adjusted life expectancy |
- A higher risk of stroke, heart failure, and renal failure associated with hypertension (African Americans)
- A higher rate of complications from diabetes (African Americans and Native Americans)
- Later-stage colon, breast, and prostate cancer at presentation (African Americans)
- Less aggressive evaluation and treatment: curative lung cancer resection, cardiac catheterization, peripheral angioplasty, renal transplantation (African Americans)
- Diabetic more likely to receive amputations (African Americans)
- Higher death rates per 1000 hospital admissions in low mortality diagnosis related groups (African Americans, Hispanics, and the uninsured)
The observed racial/ethnic health care disparities have multifactorial etiologies. Patients face multiple barriers as they engage the health care system: (1) personal and family; (2) access to the health care system (structural, financial, types of services); and (3) the quality of the available providers (Figure 3-2). These barriers can occur individually or in combination to have an additive effect on health outcomes.
Figure 3-2
Barriers and mediators of racial/ethnic health care disparities. (Adapted, with permission, from Cooper LA, Hill MN, Powe NR. Designing and evaluating interventions to eliminate racial and ethnic disparities in health care. J Gen Intern Med 2002;17:477–486. Copyright 2002 Society of General Internal Medicine.)
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