Practice Alert

10 steps for avoiding health disparities in your practice

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You are caring for a 55-year-old person with acute coronary syndrome whose angiogram shows significant obstruction in 2 arteries. Will your patient’s race, ethnicity, gender, or ability to pay influence your treatment recommendation?


 

References

We hope the answer to the question above is no. However, the evidence regarding differences in the care of patients based on race, ethnicity, gender, and socioeconomic status suggests that if this patient is a woman or African American or from a lower socioeconomic class, resultant morbidity or mortality will be higher.

Differences are seen in the provision of cardiovascular care, cancer diagnosis and treament, and HIV care. African Americans, Latino Americans, Asian Americans, and Native Americans have higher morbidity and mortality than Caucasian chemical dependency, diabetes, heart disease, infant Americans for multiple problems including cancer, mortality, and unintentional and intentional injuries.1

This article explores possible explanations for health care disparities and offers 10 practical strategies for tackling this challenging issue.

Examples of health disparities

The United States has dramatically improved the health status of its citizens—increasing longevity, reducing infant mortality and teenage pregnancies, and increasing the number of children being immunized. Despite these improvements, though, there remain persistent and disproportionate burdens of disease and illness borne by subgroups of the population (Table 1). 2,3

The Institute of Medicine in its recent report, “Unequal Treatment,” approaches the issue from another perspective: they define these disparities as “racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences and appropriateness of intervention.”4

TABLE 1
Examples of health disparities that could be changed

Disparity in mortality
Infant mortality
Infant mortality is higher for infants of African American, Native Hawaiian, and Native American mothers (13.8, 10.0, and 9.3 deaths per 1000 live births, respectively) than for infants of other race groups. Infant mortality decreases as the mother’s level of education increases.
Disparity in morbidity
Cancer (males)
The incidence of cancer among black males exceeds that of white males for prostate cancer (60%), lung and bronchial cancer (58% ), and colon and rectum cancers (14%).
Disparity in health behaviors
Cigarette smoking
Smoking among persons aged 25 years and over ranges from 11% among college graduates to 32% for those without a high school diploma; 19% of adolescents in the most rural counties smoke compared to 11% in central counties.
Disparity in preventive health care
Mammography
Poor women are 27% less likely to have had a recent mammogram than are women with family incomes above the poverty level.
Disparity in access to care
Health insurance coverage
13% of children under aged <18 years have no health insurance coverage; 28% of children with family incomes of 1 to 1.5 times the poverty level are without coverage, compared with 5% of those with family incomes at least twice the poverty level.
Source: Adapted from Health, United States, 2001.
Hyattsville, Md: National Center for Health Statistics; 2001.

Correcting health disparity begins with understanding its causes

A number of factors account for disparities in health and health care.

Population-influenced factors

Leading candidates are some population groups’ lower socioeconomic status (eg, income, occupation, education) and increased exposure to unhealthy environments. Individuals may also exhibit preferences for or against treatment (when appropriate treatment recommendations are offered) that mirror group preferences.

For example, African American patients’ distrust of the healthcare system may be based in part on their experience of discrimination as research subjects in the Tuskegee syphilis study and Los Angeles measles immunization study. Research has shown that while these issues are relevant, they do not fully account for observed disparities.

System factors

Problems with access to care are common: inadequate insurance, transportation difficulties, geographic barriers to needed services (rural/urban), and language barriers. Again, research has shown that access to care matters, but not necessarily more than other factors.

Individual factors

At the individual level, a clinical encounter may be adversely affected by physician-patient racial/ethnic discordance, patient health literacy, and physician cultural competence. Also, there is the high prevalence of risky behavior such as smoking.

Finally, provider-specific issues may be operative: bias (prejudice) against certain groups of patients, clinical uncertainty when dealing with patients, and stereotypes held by providers about the behavior or health of different groups of patients according to race, ethnicity, or culture.

Addressing disparities in practice

Clearly, improving the socioeconomic status and access to care for all people are among the most important ways to eliminate health disparities. Physicians can influence these areas through individual participation in political activities, in nonprofit organizations, and in their professional organizations.

Steps can also be taken in your own practice (Table 2).

TABLE 2
Ten practical measures for avoiding health disparity in your practice

Use evidence-based clinical guidelines as much as possible.
Consider the health literacy level of your patients when planning care and treatment, when explaining medical recommendations, and when handing out written material.
Ensure that front desk staff are sensitive to patient backgrounds and cultures.
Provide culturally sensitive patient education materials (eg, brochures in Spanish).
Keep a “black book” with the names and numbers of community health resources.
Volunteer with a nonprofit community-based agency in your area.
Ask your local health department or managed care plans if they have a community health improvement plan. Get involved in creating or implementing the plan.
Create a special program for one or more of the populations you care for (eg, a school-based program to help reduce teenage pregnancy).
Develop a plan for translation services.
Browse through the Institute of Medicine report, “Unequal Treatment” (available at www.iom.edu/report.asp?id=4475).

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