Racial and Ethnic Disparities in Health Care

The overall health of the American population has improved over the past few decades, but all Americans have not shared equally in these improvements. Among non-elderly adults, for example, 17% of Hispanic, and 16% of black Americans report they are in only fair or poor health, compared with 10% of white Americans.

How much do differences in the health care that people receive contribute to disparities in health? What strategies can overcome these differences in care? This article summarizes recent research by the U.S. Agency for Healthcare Research and Quality (AHRQ) in how these disparities can be identified and what kinds of action need to be taken to improve the access to quality healthcare for all people in the U.S.

Access to Primary Care

Primary care is the underpinning of the health care system, and research studies have shown that having a usual source of care (a "regular doctor") raises the chance that people receive adequate preventive care and other important health services.

• About 30% of Hispanic and 20% of black Americans lack a usual source of health care compared with less than 16% of whites.
• Hispanic children are nearly three times as likely as non-Hispanic white children to have no usual source of health care.
• African Americans and Hispanic Americans are far more likely to rely on hospitals or clinics for their usual source of care than are white Americans (16 % and 13% percent, respectively, compared to 8%).

Diagnosis and Treatment

Race and ethnicity influence a patient's chance of receiving many specific procedures and treatments. Of nine hospital procedures investigated in one study, five were significantly less common among African American patients than among white patients; three of those five were also less common among Hispanics, and two were less common among Asian Americans. Other studies have reveal additional disparities in patient care for various conditions and care settings including:

• Heart disease. African Americans are 13% less likely to undergo coronary angioplasty and one-third less likely to undergo bypass surgery than are whites.
• Asthma. Among preschool children hospitalized for asthma, only 7% of black and 2% of Hispanic children, compared with 21% of white children, are prescribed routine medications to prevent future asthma-related hospitalizations.
• Breast cancer. The length of time between an abnormal screening mammogram and the follow-up diagnostic test to determine whether a woman has breast cancer is more than twice as long in Asian American, black, and Hispanic women as in white women.
• HIV infection. African Americans with HIV infection are less likely to be on antiretroviral therapy, less likely to receive prophylaxis for Pneumocystis pneumonia, and less likely to be receive protease inhibitors than other persons with HIV.
• Nursing home care. Asian American, Hispanic, and African American residents of nursing homes are all far less likely than white residents to have sensory and communication aids, such as glasses and hearing aids.

Looking Beyond Income and Insurance

Disparities in health care are often ascribed to differences in income and access to insurance. Research has shown these to be important, but by no means the only factors. For instance, the proportion of Hispanic Americans with a usual source of care has declined substantially over the past decade (from 80% in 1986 to 70% in 1996). Insurance coverage has also declined, and the lack of insurance in some groups is dramatic: 37% of Hispanic men in the US have no health insurance. But the decline in insurance coverage explains only one-fifth of the decline in access to a usual source of care.

Researchers in Boston examined the quality of care provided to hospital patients with congestive heart failure or pneumonia. Quality of care was measured both by physician review and by adherence to standards of care. The researchers found no difference in quality of care for patients from poor communities compared with other patients, after adjusting for other factors. They did find, however, that African American patients received a lower quality of care than white patients.

Physician Decision-Making

A small study of physicians' decisions about whether to refer patients for cardiac catheterization, a diagnostic procedure for heart disease, provides evidence that factors other than insurance and income can influence the quality of care people get. This study, which used actors portraying similar economic backgrounds, found that black women were significantly less likely than white men to be recommended for referral, despite reporting the same symptoms.

Hospital Characteristics

In the Boston study of the quality of care, quality for African American patients was lower in non-teaching than in teaching hospitals. In another study, white patients were more likely than Hispanic and African American patients to receive invasive cardiac procedures in hospitals performing a high volume of such procedures, a factor strongly associated with the quality of cardiac care.

Cultural and Communication Barriers

Adding to the increasing evidence that cultural expectations, assumptions, and language affect the quality of care, a study in San Francisco is surveying African American, Hispanic, and white patients to examine how interpersonal processes -- the way patients and clinicians interact -- affect the health care that patients get and the outcomes of their care.

Translating Research into Practice

One way to begin to address disparities in the quality of care is to improve clinicians' abilities to apply the results of previous research to minority patients whenever relevant research exists. Tools like the National Guideline Clearinghouse can be used to give clinicians better access to evidence-based information about diagnosis and treatment. Patients can be better informed through the use of multilingual informational materials like immunization guides, childcare guides, and information on diet and other aspects of preventive health. The AHRQ is funding research that involves partnerships between academic researchers and health care providers who serve predominantly minority communities.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.