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Race-Based Quality Gaps Persist for Older Americans
By Karen Pallarito, HealthDay Reporter
August 17, 2005
Despite some improvement in outpatient care, the overall quality of care that older, black Americans receive still lags that of white seniors, while gaping differences persist in surgical care, three new studies reveal.
In one study, researchers at Emory University School of Medicine in Atlanta found that black women were much less likely to receive certain recommended treatments for a heart attack, compared with white men. Black women had the highest adjusted death rate among all sex and racial groups.
Another study examining the use of nine major surgical procedures found "no meaningful, consistent reductions" in racial differences over a decade-long period, a team from Harvard School of Public Health reported.
The only encouraging news came from researchers at Harvard and Brigham and Women's Hospital in Boston, who examined the use of nine common outpatient tests, screenings and treatments among patients in Medicare managed-care plans. The study found that quality-of-care overall had improved for both blacks and whites while racial gaps narrowed for seven of the nine measures studied.
Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality (AHRQ), said the studies add to an abundance of evidence documenting large and substantial disparities between "best practices" and the care that people receive -- gaps that are greater still for racial and ethnic groups.
The findings, she said, raise important questions: "Will overall efforts on quality close the gap as we're improving quality of care?" Or, she wondered, will more "focused efforts" be required to erase the racial divide?
The three studies appear in the Aug. 18 issue of the New England Journal of Medicine.
Public health experts believe documenting racial and ethnic disparities in health care is a crucial step toward correcting the problem.
"We can't improve what we don't measure," said Dr. Amal N. Trivedi, research fellow at Brigham and Women's general medicine division and lead author of the study of clinical care in Medicare managed-care plans.
Still, tackling stubborn disparities remains a huge challenge. As these studies demonstrate, broad-based efforts to improve overall quality may not be enough to end racial gaps.
To that end, nine major health insurers in collaboration with AHRQ, the federal government's lead agency on quality improvement, are participating in a national initiative to tackle race-based inequities and improve the quality of care delivered to people with diabetes and other conditions. The goal of the three-year project, announced last December, is to develop effective measures that can be replicated by other insurers.
"We're very excited that we'll be learning from these plans as they go, and we'll learn what works under various circumstances," Clancy said.
In an accompanying editorial in the journal, Dr. Nicole Lurie, director of the RAND Center for Population Health and Health Disparities, applauded the initiative but insisted that insurers and health care providers "cannot solve this problem alone." More widespread redesign of health care delivery systems will be required, "and this change will probably be longer in coming," she wrote.
Each of the new studies seeks to document changes in racial gaps over time.
Harvard's Dr. Ashish K. Jha and colleagues examined the use of nine major surgical procedures among blacks and whites enrolled in Medicare from 1992 through 2001. These included heart bypass, carotid artery, and total hip replacement surgeries. Despite increased national and local attention to the issue of racial disparities, the authors found no evidence that disparities were reduced over the decade.
A disappointing lack of progress was also seen in the area of heart attack treatment. Emory's Dr. Viola Vaccarino and colleagues started with a sample of nearly 600,000 patients hospitalized for heart attack between 1994 and 2002. To avoid racial or sex variation in treatment, her team identified groups of patients whom they considered "ideal candidates" for four different interventions.
"What we found in general was differences in race seem to be more important than differences in gender," Vaccarino said. As compared with white men, for example, fewer black men and black women received reperfusion therapy, a type of treatment for restoring blood flow to the heart that involves the administration of clot-busting drugs or artery-clearing angioplasty.
Black women received the fewest recommended treatments and also had the highest mortality rate among all sex and racial groups, "so this is really concerning," Vaccarino added.
If there's a ray of hope, it's the progress seen in reducing disparities in care provided by Medicare managed-care plans. Over a seven-year period, the gap between blacks and whites narrowed for seven measures of care.
However, in two crucial areas -- glucose control for people with diabetes and cholesterol control for heart patients -- racial gaps were not reduced, the researchers at Harvard and Brigham and Women's found.
"The take-home message is that more work needs to be done," said Marsha Lillie-Blanton, a vice president and director of the Henry J. Kaiser Family Foundation's Race/Ethnicity and Health Care Program. "We shouldn't rest and say there are no problems."
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