Health-Care Racial Divide Hospital-Based

Study says it's not due to racism on individual level

WEDNESDAY, Oct. 6, 2004 (HealthDayNews) -- Racial and ethnic disparities in health care are at least partially due to differences in care between hospitals and not racism on an individual level, a new study says.

Until now, many experts had assumed that person-to-person racism accounted for differences in care. The problem, however, seems to be much more complicated than that, according to the report in the Oct. 6 issue of the Journal of the American Medical Association (JAMA).

"We have been thinking that this represented racism at the patient level," said senior study author Dr. Harlan Krumholz, a professor of medicine at Yale University School of Medicine. "Cultural sensitivity is a good thing all the way around, but a large percentage of this difference was accounted for by the type of hospital that people went to."

"The issue of hospitals and health-care systems as being more at the heart of these differences in health care seems to ring true," said Dr. Margaret Winker, deputy editor of JAMA and author of an accompanying editorial. "Rather than being a simple function of unequal treatment by physicians and other healthcare professionals, the issue appears to be more complex and involves hospitals and healthcare systems."

Previous studies had indicated that patients who belonged to racial and ethnic minorities took longer to receive lifesaving blood-clot-dissolving therapy, as well as percutaneous coronary intervention or angioplasty. The former is known as door-to-door time and the latter as door-to-balloon time.

For this study, Krumholz and his colleagues analyzed admission and treatment data from the National Registry of Myocardial Infarction. The registry included information on 73,032 patients who received fibrinolytic therapy, and 37,143 who received angioplasty at hospitals from Jan. 1, 1999, through Dec. 31, 2002.

Door-to-door times were longer for patients identified as black (41.1 minutes), Hispanic (36.1 minutes), and Asian/Pacific Islander (37.4 minutes) when compared with patients identified as white (33.8 minutes).

Door-to-balloon times were also longer for black patients (122.3 minutes) and for Hispanic patients (114.8 minutes) than for white patients (103.4 minutes).

"We found marked discrepancies in the treatment of patients based on their race and ethnicity," Krumholz confirmed. "In the case of treatment with angioplasty, it was as much as a 20-minute difference, which is substantial and concerning. This is a difference with a consequence. We know the shorter the time, the better the outcome."

At the same time, these differences were significantly reduced after accounting for differences in average times to treatment for individual hospitals. Door-to-balloon time between black and white patients was reduced by 33 percent, while the difference between Hispanic and white patients was reduced by almost 75 percent.

The study did not look specifically at why hospitals might differ in these respects. "It seems that hospitals with poor performance in time to treatment must have disproportionately been caring for patients who were racial/ethnic minorities," Krumholz said. "Whites are more likely to be at hospitals that are faster." And hospitals that serve primarily white patients may simply have more resources, including staff, than hospitals that serve racial and ethnic minorities.

That being said, taking hospitals into account didn't eliminate disparities completely. "We're not trying to say that it's all the hospital," Krumholz said. "If we're going to eliminate disparities in this country, we're going to have to have a dual approach."

"It's a larger issue of inequities that exist in the health-care system," Winker added. "In terms of fixing the problem, we're a long ways from that, but the first step is always to identify where the problems are."

The research highlights some of the difficulties of studying race and ethnicity. "It's an easy thing to measure theoretically. But it's a more complex topic than it is usually given credit for, since race and ethnicity often coexist with other, often more important factors, such as socioeconomic factors, cultural milieu, etc.," Winker said

Dr. Paul Underwood, president of the Association of Black Cardiologists and an interventional cardiologist at North Phoenix Heart Center in Phoenix, Ariz., said that the ability to determine where some of the obstacles are to delivering rapid reperfusion would be critical in working through those obstacles.

Once it was determined that resources are needed to be able to deliver appropriate care, "those resources should be given to all hospitals," he added.

More information

Visit the Association of Black Cardiologists for more on race and health care.

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