Racial Disparities in Cardiac Care
(Source: U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ)) African-American adults are less likely to be diagnosed with coronary heart disease, but they are more likely to die from heart disease. Knowing what steps can be taken by patients, providers and the community to improve the quality of cardiac care for all American is critical to an effective and efficient health care system.
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 nonelderly adults, for example, 17 percent of Hispanic, and 16 percent of black Americans report they are in only fair or poor health, compared with 10 percent 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? These are questions for health services research, and ones that researchers supported by the Agency for Healthcare Research and Quality (AHRQ, formerly the Agency for Health Care Policy and Research) have begun to address.
Identifying disparities in care
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 raises the chance that people receive adequate preventive care and other important health services. Data from AHRQ's Medical Expenditure Panel Survey (MEPS) reveal that:
- About 30 percent of Hispanic and 20 percent of black Americans lack a usual source of health care compared with less than 16 percent 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, v. 8 percent).
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 AHRQ-supported studies have revealed additional disparities in patient care for various conditions and care settings including:
- Heart disease. African Americans are 13 percent 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 percent of black and 2 percent of Hispanic children, compared with 21 percent 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 followup 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.
- Human immunodeficiency virus (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 receiving protease inhibitors than other persons with HIV. An HIV infection data coordinating center, now under development, will allow researchers to compare contemporary data on HIV care to examine whether disparities in care among groups are being addressed and to identify any new patterns in treatment that arise.
- 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. A new study of nursing home care is developing measures of disparities in this care setting and their relationship to quality of care.
Identifying that disparities in care exist is important, but it is not enough. Now, researchers are also beginning to focus on why these disparities exist, which disparities actually indicate poor-quality care, and how to develop strategies to address them.
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 percent in 1986 to 70 percent in 1996). Insurance coverage has also declined, and the lack of insurance in some groups is dramatic (among Hispanic men, for instance, 37 percent have no health insurance). Nonetheless, declines in insurance coverage explained only one-fifth of the change in access to a usual source of care.
In another recent study, AHRQ-funded 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.
A small study of physicians' decisions about whether to refer patients for cardiac catheterization, a diagnostic procedure for heart disease, provides supportive 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. (Differences between other groups studied were not statistically significant.)
In the Boston study of the quality of care, quality for African American patients was lower in nonteaching 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 of cultural expectations, assumptions, and language as factors affecting the quality of care, an ongoing study by AHRQ-supported researchers 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.
Key Point 1
The notion of disparities in health care is an uncomfortable subject for most of us. However, acknowledging that inequities in care may exist is the first step to improving care and achieving the best possible health care system for an increasingly diverse population. Delivering healthcare will not just save lives for some people but it’s going to save money.
Key Point 2
Improving cardiovascular care requires coordination, creativity and commitment. It is a partnership among hospitals, providers, communities, families and patients. You have to play your part to change your life and get the care you deserve.
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