Health Disparities and Multicultural Practice

Clarence H. Braddock III, MD, MPH, FACPAssociate Professor of Medicine

Associate Dean, Medical Education

Goals for this afternoon

Why are we talking about this? To recognize the challenge of health disparities to medical practice

As a lens through which to view your training

To contemplate your future role in addressing

Overview

Discuss extent of disparities View examples of disparities and of multi-cultural practice

Gain insight into our own biases

How extensive are How extensive are healthcare healthcare

disparities?disparities?

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Unequal TreatmentUnequal Treatment Generally speaking, how often Generally speaking, how often do you think our health system do you think our health system treats people treats people unfairly based on unfairly based on their racetheir race or ethnic or ethnic background?background?

1=Very often1=Very often 2=Somewhat often2=Somewhat often 3=Rarely 3=Rarely 4=Never4=Never

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ResponsesResponses% saying “very/somewhat % saying “very/somewhat

often”often” Physicians 29%Physicians 29%

White physicians 26%White physicians 26% Asian physicians 33%Asian physicians 33% Latino physicians 52%Latino physicians 52% Black physicians 77%Black physicians 77%

Public 47%Public 47%Kaiser Family Foundation National Survey of Physicians, 2002,

Survey of Race, Ethnicity and Medical Care: Public Perceptions and Experiences, 1999

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Cardiovascular careCardiovascular care

Rate your agreement with this Rate your agreement with this statement:statement:““African Americans with heart African Americans with heart disease are just as likely as disease are just as likely as whites who have heart disease whites who have heart disease to get specialized medical to get specialized medical procedures and surgery.”procedures and surgery.”

1=Agree1=Agree 2=Disagree2=Disagree 3=Not sure3=Not sure

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ResponsesResponses%saying “Disagree”%saying “Disagree”

Physicians 65%Physicians 65% White physicians 67%White physicians 67% Asian physicians 54%Asian physicians 54% Latino physicians 68%Latino physicians 68% Black physicians 89%Black physicians 89%

Public 37%Public 37%Kaiser Family Foundation National Survey of Physicians, 2002,

Survey of Race, Ethnicity and Medical Care: Public Perceptions and Experiences, 1999

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Summary of disparities Summary of disparities literatureliterature

White patients receive more White patients receive more healthcare services and achieve healthcare services and achieve better outcomes than African-better outcomes than African-American, Latino, Native American, American, Latino, Native American, Asian-American patientsAsian-American patients

Cardiovascular disease: MI, strokeCardiovascular disease: MI, stroke AsthmaAsthma Cancer: breast, lung, colorectalCancer: breast, lung, colorectal Screening and preventive servicesScreening and preventive services HIV/AIDS HIV/AIDS Psychiatric carePsychiatric care

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Reasons for healthcare Reasons for healthcare disparitiesdisparities

Would you say the following statement Would you say the following statement is a is a major reason, minor reason, or major reason, minor reason, or not a reasonnot a reason why the health care why the health care system treats people unfairly based system treats people unfairly based on race or ethnic background?on race or ethnic background?““Many people from minority groups live Many people from minority groups live

in areas where there are fewer in areas where there are fewer doctors or have trouble with access”doctors or have trouble with access”

1=Major reason1=Major reason 2=Minor reason2=Minor reason 3=Not a reason3=Not a reason

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ResponsesResponses% saying “major reason”% saying “major reason”

Physicians 58%Physicians 58% White physicians 61%White physicians 61% Asian physicians 58%Asian physicians 58% Latino physicians 59%Latino physicians 59% Black physicians 50%Black physicians 50%

Public 40%Public 40%Kaiser Family Foundation National Survey of Physicians, 2002,

Survey of Race, Ethnicity and Medical Care: Public Perceptions and Experiences, 1999

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““The preponderance of studies…find The preponderance of studies…find that even that even after adjustment for potential after adjustment for potential confounding factors…racial and ethnic confounding factors…racial and ethnic disparities in cardiovascular care disparities in cardiovascular care remain.”remain.” AccessAccess Disease severityDisease severity Site of care (e.g. geographic Site of care (e.g. geographic variation or hospital type)variation or hospital type)

Disease prevalenceDisease prevalence Co-morbidities or clinical Co-morbidities or clinical characteristicscharacteristics

Refusal ratesRefusal rates Overuse of servicesOveruse of services

IOM, IOM, Unequal Treatment, Unequal Treatment, 20032003

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Evidence of provider biasEvidence of provider bias

Actors portrayed patients with Actors portrayed patients with same clinical characteristics same clinical characteristics but different gender and racebut different gender and race

Physicians viewed videotapes; Physicians viewed videotapes; made recommendations for made recommendations for managing chest painmanaging chest pain

Schulman, NEJM 1999

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Evidence of provider biasEvidence of provider bias

Schulman, 1999

The study examined: The study examined: physician recommendations for physician recommendations for referralsreferrals

assessment of personality traitsassessment of personality traits predictions of behaviorpredictions of behavior

Multivariate analysis of predictorsMultivariate analysis of predictors adjusted for physician assessment of adjusted for physician assessment of probability and severity of symptomsprobability and severity of symptoms

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Schulman, K. A. et al. N Engl J Med 1999;340:618-626

Patients as Portrayed by Actors in the Video Component of the Survey

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Evidence of provider biasEvidence of provider bias

Schulman, 1999

Catheterization referrals differ Catheterization referrals differ significantly:significantly: Black patients less likely to be Black patients less likely to be referred than white patients referred than white patients

Odds ratio 0.6, p = 0.02Odds ratio 0.6, p = 0.02 Women less likely to be referred Women less likely to be referred than men than men

OR 0.6, p = 0.02 OR 0.6, p = 0.02 In a combined analysis, black women In a combined analysis, black women fared the worst as compared to white fared the worst as compared to white males males

OR 0.4, p = 0.004OR 0.4, p = 0.004

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Evidence of provider biasEvidence of provider bias

Schulman, 1999

Physicians more likely to attribute Physicians more likely to attribute negative personality traits to black negative personality traits to black patients and women. patients and women. Categories Categories includedincluded::

White women perceived sadder, more White women perceived sadder, more worriedworried

Black women more likely to over-Black women more likely to over-report symptomsreport symptoms

White men more likely to sueWhite men more likely to sue

Health Disparities

Robert Phillips story