printable versionNo bias in doctor's office, study finds
BY MATTHEW EARLY WRIGHT
A new study from the School of Medicine has found that once U.S. patients visit a doctor for outpatient care, their race and ethnicity make little difference in the care they receive. But the study also found that health-care providers have a lot of room for improvement when it comes to caring for all of their patients. In fact, the study suggests only limited improvements in outpatient care over a 10-year period.
"We observed similar, though less-than-optimal, outpatient care across all racial and ethnic groups using visit-based, physician-provided national data," said Jun Ma, MD, PhD, research associate at the Stanford Prevention Research Center and lead author of the study that appears in the June 27 issue of the Archives of Internal Medicine. The results should be interpreted carefully, Ma said, as the data set represents only a small snapshot of the nation's health-care landscape—namely, those who obtained care in the first place.
Ma's collaborator, Randall Stafford MD, PhD, associate professor of medicine, added: "The results of our study do not contradict past research that suggests large disparities in health-care outcomes. Our findings simply indicate that these disparities do not arise primarily from unequal treatment in doctors' offices."
Ma and Stafford designed the study to fill in details on outpatient care missing from two annual government reports: the National Healthcare Quality Report and the National Healthcare Disparities Report. These reports collectively documented both a substandard level of care from providers across the country and a pervasive gap in quality between whites and minorities. For example, the disparities report found that minorities are more likely than whites to die from HIV/AIDS, and they are also less likely to receive routine childhood immunizations.
While Ma and Stafford's study confirms a suboptimal quality of outpatient care, they were surprised by the results regarding equality of care. "Our result was contrary to our hypothesis," Ma said.
The researchers compared outpatient data from 1992 and 2002, broken down by race and ethnicity. Of 23 quality measures designated by the researchers, such as appropriate prescription of antidepressants and dietary counseling for example, only two showed significant statistical differences with regard to race: blacks were more likely to receive angiotensin-converting enzyme inhibitors for congestive heart failure, and whites were less likely to receive unnecessary antibiotics for common colds.
As unexpected as this result might be, it does not mean that racial and ethnic health-care disparities do not exist. The study, Ma said, does not provide information about access to health care, since outpatient information accounts for patients who have already accessed the system. "We speculate that racial and ethnic disparities may arise more from unequal health-care access and utilization than from direct differences in treatment once a patient is in the system," she said.
This gap in access and use could be due to many factors. Minorities might have difficulty communicating with their health-care providers, they might lack access to educational materials or they might not have insurance coverage, Ma said.
To better understand the problem, she believes there are several important questions to ask. First, what underlying factors stand in the way of equitable access to health coverage? Second, why do patients with adequate insurance coverage not seek treatment when it is needed? Third, why do patients sometimes fail to return for proper follow-up care?
So far, no study has been able to offer a clear explanation as to what causes disparities in health care—either in terms of access or treatment quality. The key, Ma said, is more detailed data that better represent the nation's minority populations as a whole, not just those who receive outpatient care. She also sees the need for data that follow individual patients through an entire treatment cycle, from first visit to final outcome, to help understand where and why disparities exist and how they can be eliminated.
Stafford agreed, noting that this study points to the next step. "The findings suggest a need to look at health-care access as a root cause of health disparities, rather than focusing on the treatment of those patients that make it to physicians' offices," he said. "Strategies to reduce disparities will need to address the underlying social, cultural and economic issues faced by minority patients as they try to access the health-care system."