Medicine: Studies Find Race Gap

The Institute of Medicine may not seem like a revolutionary body. But in 2001, it issued a challenge to the nation—to strive for equal health care for all citizens, regardless of gender, ethnicity, geographic location and socioeconomic status. The impetus was clear: Too many studies were showing that African-Americans were receiving poorer medical care than whites. Five years later, how are we doing?

Not so well, according to a pair of new studies. The first one, appearing tomorrow in the Journal of the American Medical Association, looked at 334,204 black and white members of 151 Medicare plans—and found that only one plan was delivering equally well for blacks and whites, and even this plan was making the grade on only two out of four measures. The study didn't aim to assess care in the doctor's office per se, according to Dr. John Ayanian, associate professor of medicine and health care policy at Harvard Medical School and senior author of the study. Ayanian and Dr. Amal Trivedi of Brown University already put that issue under the microscope in an August 2005 study in the New England Journal of Medicine. The earlier study found that between 1997 and 2003, there was "substantial improvement" for black Medicare recipients in "simple processes of care"—in other words, whether or not the physician performs the appropriate tests and makes sure patients receive the right prescriptions.

The new study went beyond office care to see how patients are actually faring. Are those with diabetes successfully controlling blood sugar and also keeping cholesterol levels in check? Are people with hypertension keeping their blood pressure down? Are patients who've suffered heart attacks or had heart surgery managing their cholesterol? On those four measures, the results were sobering. For the most part, the racial gaps were just as great in high-scoring plans as low-scoring ones. "Many plans eliminated racial disparities on a single measure," says Ayanian. "But only one achieved both high quality outcomes and small disparities on two of the measures. No plan achieved those goals on three or four measures."

But why should that be, if the overall quality of medical care is improving, as shown in the earlier study? There are many possible reasons. More often than whites, African-Americans find they cannot afford expensive medications, such as cholesterol-lowering statins. Their communities tend to have more limited options for exercising and eating right. Those problems don't lend themselves to quick fixes. But the study did point to one approach that could help. Medicare plans receive monthly payments from the government to meet the needs of enrollees. Ayanian says more of that money may need to be directed toward social support programs, such as meetings with nutritionists and health educators or more follow-up appointments with the physicians themselves for patients who are having trouble controlling blood sugar, cholesterol or blood pressure. That may sound expensive, but as he points out, it's cheaper than the consequences of doing nothing—namely, treating resulting heart attacks, strokes or kidney failure.

The JAMA study looked only at black and white participants in Medicare plans. Another new study in the journal Ethnicity and Disease looked more broadly at white, black, Hispanic and Asian adults throughout New York City. Luisa Borrell, assistant professor of epidemiology at Columbia University's Mailman School of Public Health, combed through New York City data zip code by zip code and found that in highly segregated neighborhoods—specifically, those with the highest concentration of black residents—people were 10 percent more likely to report their health as poor. "We know that there's a correlation between how people rate their health and greater mortality under the age of 65," she says.

The findings apparently weren't due to explicit racism. Everyone in the minority-dominated neighborhoods—white, black, Hispanic and Asian—tended to give their health lower marks. "It relates to the poverty level, the quality of food, the quality of life, the quality of health care," says Borrell. "In poorer areas, there are fewer green spaces to play in, fewer shops selling fresh fruits and vegetables, more cigarette ads. We're not blaming the victim. We're blaming the social structure."

Grappling with social issues will clearly take time. The question is whether changes in the medical system itself can make enough headway to help compensate—and meet the IOM's challenge.

Medicine: Studies Find Race Gap | News