Disparate Healthcare by Kevin Klauer, DO, EJD

Efficacy and safety or diagnostic and treatment strategies tend to be our focus when critically appraising the literature or considering adoption of new practice trends. However, we perhaps spend less time than we should on the social implications influencing the care we deliver.

Understandably so, clinicians work very hard to sift through the dearth of “evidence” to make rational choices for their patients. Thus, mastering a clinical topic, solidifying their position on a given issue and incorporating those decisions into practice should be enough. Unfortunately, it’s not.

Practicing the art of medicine is complex. This “art” may result in unnecessary variation in practice, which should be minimized by quality data and evidence. However, the “artist” is frequently influenced by more than just evidence, and such influences may not be obvious or even recognized or acknowledged by those being influenced. Unconscious bias is the silent killer of knowledge translation.

Cultural sensitivity and diversity are not only terms defining how we perceive, interact with and treat others, but they also impact how we care for our patients. Cultural sensitivity in health care has been defined as health care delivered that is relevant to patients’ needs and expectations1. In addition, it has been noted that cultural sensitivity and cultural competency are negatively associated with ethnicity or race-related health disparities2.

What is fascinating is that despite the recognition of the social benefits of cultural sensitivity toward others, it is indisputable that disparities in care delivery exist based on cultural characteristics and differences, with ethnicity and gender being the most commonly cited. In other words, article after article has shown that female and African American patients often receive different care than their male and Caucasian counterparts with the same disease or similar presentation. Pain management and the evaluation and management of possible acute coronary syndrome are well-publicized examples of this phenomenon.

A substantial barrier to the broad acceptance of this concern is the quality of the available evidence. Combined with a dose of realism, the evidence is enough to concede the fact that disparities in care delivery exist. The question that the evidence doesn’t adequately address is, “Why?” The preponderance of evidence, despite various methodological limitations, seems to routinely point to disparities in care.

In a 1995 study, Raftery, et al. reported that, “severity of patient pain rather than gender stereotyping appeared to correlate most with pain-management practices3.” This study evaluated the provision of pain medication, the strength of analgesics and use of multiple pain medications in 190 patients (110 female). Providers who were surveyed about the patient’s pain and pain management evaluated the patients. According to those surveyed, women reported more pain, they were perceived to have more pain, and they received more medications and more potent analgesics. Despite the fact that female patients were treated more aggressively, the investigators reported that gender was not an independent predictor of pain management. Interestingly, they reported that gender stereotyping did not correlate with pain management practices, but 60 of the 84 reviewers were male which seems to invalidate this conclusion, as the results were strongly influenced by male perception of female patients’ pain.

In an equally challenged study, physicians were given hypothetical vignettes to assess their treatment decisions4. With nephrolithiasis, male physicians prescribed higher doses of hydrocodone for white compared to African American patients (426mg v. 238mg), while female physicians did exactly the opposite (335mg v. 161mg). For intractable back pain, men prescribed more hydrocodone for men, and female physicians prescribed more for female patients. The authors concluded that disparity in pain management only existed when gender of the physician was considered. Data mining yields confounding results.

These first two studies reflect suspicion for gender and ethnic differences in pain management, but the poor quality of the evidence disallows firm conclusions.

Todd, et al. reported no disparity between patient and physician pain assessments among Hispanic and white patients5. In 1993, the prior year, Todd noted that Hispanic patients with isolated long-bone fractures were twice as likely as their white counterparts to not receive any pain medication. Following logistic regression analysis, controlling for multiple variables simultaneously, ethnicity was the strongest predictor of the administration of analgesics6. Todd noted similar findings comparing African American patients to white patients with long-bone fractures7. Conversely, in 2008, Bijur found no differences based on ethnicity among 1,239 patients with suspected long-bone fractures8. In 2011, in a retrospective cohort study of over 20,000 patients with abdominal or back pain, non-white patients were less likely to receive analgesics and waited longer for opioid analgesics than white patients9.

The data are unclear and are likely to remain so. Small sample sizes, retrospective analyses, hypothetical vignettes, etc. are unlikely to answer these important questions. However, a prospective, randomized, controlled trial isn’t really feasible to study this question. When individual decisions are made which may not be scientifically based, science may not provide us with the answer. Consider this, “Why do we continue to ask this question?” If, even occasionally, unconscious bias negatively influences management decisions, in this case pain management, then we have an obligation to try to identify the reasons and eliminate them. Marcus Martin summarized, “Perceived or actual ethnic disparities in the treatment of patients with pain presenting to the ED must be eliminated. Nonbiased pain management must be instilled in our trainees, and ED directors and staff must examine current local pain management practices10.”

Access to equitable management of acute coronary syndrome has been discussed in the literature for decades. Johnson et al reported, in their prospective follow up study of 3,031 patients admitted from the emergency department for acute chest pain, that even after adjusting for presenting signs and symptoms and other variables African Americans were less likely to be admitted (OR 0.69), and if admitted, were less likely to be admitted to the coronary care unit (OR 0.81). Although the likelihood of African American patients to receive PCI was similar (OR 0.86), they were less likely to receive coronary artery bypass grafts (OR 0.24)11.

Kramer studied the decline of United States mortality rates from heart disease from 1973–2010. Although overall declines have been reported, this study noted that the rate of decline was less for African Americans. Three themes were identified. “First, the magnitude of racial disparities in heart disease mortality varied substantially by age, particularly among women, with the largest disparities being observed among the youngest adults. Second, the change in period-specific disparities between 1973 and 2010 was modest for both men and women. Finally, cohort trends indicative of risk differences between generations were notable, with growing black-white disparities, particularly for men born between 1920 and 1960, suggesting exposures with impacts over the life course that slowed the rate of decline for black men relative to white men born during the mid-20th century12.” The study emphasizes that life course exposures are drivers for future outcomes and higher rates of hypertension in African Americans and barriers to healthcare access that contribute to the disparities noted in mortality due to heart disease.

The National Registry for Myocardial Infarction (NRMI) database was assessed from 1994–2002. As with other retrospective reviews of registry data, there are inherent limitations. However, this large database of nearly 600,000 patients with myocardial infarction is consistent with other studies noting disparate care based on gender and ethnicity. With respect to reperfusion therapy, when compared to white males, white females and African American males and females received reperfusion therapy less often with adjusted odds ratios of 0.97, 0.91 and 0.89, respectively. Specifically for PCI, compared to white males, the adjusted odds ratios were 0.91, 0.82 and 0.76. These data suggest disparities in the management of myocardial infarction based on gender and ethnicity13.

In another assessment of NRMI data, Bradley, et al reported that door-to-needle (thrombolytics) and door-to-balloon (PCI) times were significantly longer for African Americans compared to white patients with myocardial infarction14.

In another large database of patients admitted for STEMI, patients between the ages of 18 and 59 years were assessed between 2004 and 2011 to determine gender differences in revascularization strategies, mortality and hospitalization length of stay. Compared to men, women were less likely to receive reperfusion therapy. Adjusted odds ratios for PCI, CABG and thrombolysis were 0.74, 0.61, 0.80, respectively. In addition, hospital mortality was higher for women (4.5% v. 3.0%, adjusted odds ratio: 1.11)15.

Although pain management and acute coronary syndrome are two of the most commonly published topics investigating disparity, there are many areas of medicine that have been studied, validating the concerns over disparate care and noting that researchers have identified disparity in care as pervasive and an important social medicine issue in need of a resolution. Although reviewing additional clinical topics subject to disparity is beyond the scope of this essay, it is important to recognize the breadth of the issue. Bringing even greater relevance to this topic is that disparate care appears to spare no one and extends even to our most vulnerable of patients, children. Natale, et al reported disparate care in pediatric trauma patients who suffered blunt abdominal trauma16. Among 10,825 children who presented to 20 different emergency departments, abdominal CTs were ordered at different rates for different ethnicities, 51.8% for white children, 44.2% for Hispanics and 32.7% for African Americans. Although the likelihood for performance of an abdominal CT was not significantly different comparing Hispanic to white children, CTs were less likely to be performed in African American children (OR: 0.8).

The quality of the data surrounding the issue of healthcare disparity is an obstacle to the acknowledgment of this important issue. Without irrefutable data informing a unified consensus, some may believe that the imperfect data that have been published are merely artifact or due to influences beyond the clinician’s control. However, the volume of published data on this topic and the wide breadth of clinical entities reported to be impacted by this phenomenon make dismissing these concerns not only unacceptable, but also completely illogical. We may not have a clear understanding of the contributing factors resulting in disparate care. However, cultural sensitivity is a fundamental for the delivery of equitable, high quality patient care. Awareness of this issue should prompt every clinician to evaluate their approach to patients, identifying unconscious biases to actively avoid them from influencing the care that they provide.

Kevin Klauer, DO, EJD

Chief Medical Officer, Emergency Medicine

Chief Risk Officer and Executive Director

Patient Safety Organization, TeamHealth

Assistant Clinical Professor

College of Osteopathic Medicine

Michigan State University

References

1. Majumdar B, Browne G, Roberts J, Carpio B. Effects of cultural sensitivity training on health care provider attitudes and patient outcomes. Journal of Nursing Scholarship. 2004; 36:161–166.

2. Betancourt JR. Racial and ethnic disparities in health care: No one suspect, no one solution. Delaware Medical Journal. 2005; 77:333–334.

3. Kathleen A Raftery, Rebecca Smith-Coggins, Alice HM Chen, Gender-Associated Differences in Emergency Department Pain Management, Annals of Emergency Medicine, Volume 26, Issue 4, October 1995, Pages 414–421, ISSN 0196–0644, http://dx.doi.org/10.1016/S0196-0644(95)70107-9.

4. Carol S. Weisse PhD1, Paul C. Sorum MD, PhD, Kafi N. Sanders BS, and Beth L. Syat BS Do Gender and Race Affect Decisions About Pain Management? Journal of General Internal Medicine. Volume 16, Issue 4, pages 211–217, April 2001.

5. Todd KH, Lee T, Hoffman JR. The Effect of Ethnicity on Physician Estimates of Pain Severity in Patients With Isolated Extremity Trauma. JAMA. 1994;271(12):925–928.

6. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a Risk Factor for Inadequate Emergency Department Analgesia. JAMA. 1993;269(12):1537–1539.

7. Todd KH, et al. Ethnicity and analgesic practice. Ann Emerg Med. 2000 Jan;35(1):11–6.

8. Polly Bijur, et al. Race, Ethnicity, and Management of Pain from Long-bone Fractures: A Prospective Study of Two Academic Urban Emergency Departments. ACADEMIC EMERGENCY MEDICINE 2008; 15:589–597.

9. Mills AM, et al. Racial disparity in analgesic treatment for ED patients with abdominal or back pain. Am J Emerg Med. 2011 Sep;29(7):752–6.

10. Martin ML. Ethnicity and analgesic practice: an editorial. Ann Emergy Med. January 2000;35:77–79.

11. Johnson PA, Lee TH, Cook EF, Rouan GW, Goldman L. Effect of Race on the Presentation and Management of Patients with Acute Chest Pain. Ann Intern Med. 1993;118:593–601.

12. Michael R. Kramer, Amy L. Valderrama, Michele L. Casper. Decomposing Black-White Disparities in Heart Disease Mortality in the United States, 1973–2010: An Age-Period-Cohort Analysis. Am J Epidemiol. 2015;182(4):302–312.

13. Vaccarino V, Rathore SS, Wenger NK, Frederick PD, Abramson JL, Barron HV, Manhapra A, Mallik S, Krumholz HM, National Registry of Myocardial Infarction Investigators. Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002. N Engl J Med. 2005;353:671–82.

14. Bradley EH, Herrin J, Wang Y, et al. Racial and ethnic differences in time to acute reperfusion therapy for patients hospitalized with myocardial infarction. JAMA. 2004;292:1563–1572.

15. Khera S, Kolte D, Gupta T, et al. Temporal Trends and Sex Differences in Revascularization and Outcomes of ST-Segment Elevation Myocardial Infarction in Younger Adults in the United States. J Am Coll Cardiol. 2015;66(18):1961–1972.

16. Natale JE, Joseph JG, Rogers AJ, et al. Relationship of Physician-identified Patient Race and Ethnicity to Use of Computed Tomography in Pediatric Blunt Torso Trauma. Acad Emerg Med. May 2016;23(5):584–590.

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