Minority Health: Recent Findings
AHRQ Pub. No. 12(13)-P005-EF (Replaces AHRQ Pub. No. 09-P002) February 2013
PDF is attached at the bottom of this page
See also VitaminDWiki
- Overview Dark skin births and Vitamin D
- Overview Dark Skin and Vitamin D
- African-Americans at high risk of obesity and diabetes - 2011
- IBD surgery 5X more likely for non-caucasians with low vitamin D – Oct 2012
- Differences in black and non-black mortality and vitamin D – Oct 2012
- Forearm fracture 3.5X more often in black children with low levels of vitamin D – Sept 2012
- 98 percent of black women had less than 20 ng of vitamin D – July 2012
- Blacks with HIV were 3.5X more likely to be vitamin D deficient than whites – May 2012
- Hypothesis: Blacks get more cancer than whites due to lower levels of vitamin D – June 2012
- Vitamin D and Inuit (dark skin) – April 2012 which has the following material
The health disparity for dark skinned people is almost the same as whites having a low level of vitamin D
|Black vs White||White: low D vs high D|
Do blacks have a 5 year life penalty due to low vitamin D from JAMA 2007; Heart Disease 1.3 years, HIV 0.6 years, Perinatal death 0.5 years, Stroke 0.4 years, Lung cancer 0.3 years, Other cancer 0.3 years, Diabetes 0.3 years, Prostate cancer 0.3 years, Septicemia 0.2 years, Hypertension 0.2 years, Nephritis 0.2 years, Homicide 1.0 years (depression?), Unintentional injuries 0.4 years (drugs, autos, falls), Perinatal death 0.5 years, Homicide 1.0 years (some of which is due to depression)
The Black/White survival discrepancy peaks at age 78: chronic illness
- Black Sudanese children 350X more likely to have rickets than other Australians – April 2012
- Disadvantaged get less sun and have poor health in the North– Aug 2011
- All items in Far From Equator
- All items in Skin Color and vitamin D
The mission of AHRQ is to improve the quality, safety, efficiency, and effectiveness of health care by:
• Using evidence to improve health care.
• Improving health care outcomes through research.
• Transforming research into practice.
The overall health of the American population has improved over the past few decades, but not all Americans have benefitted equally from these improvements. Minority populations, in particular, continue to lag behind whites in a number of areas, including quality of care, access to care, timeliness, and outcomes. Other health care problems that disproportionately affect minorities include provider biases, poor provider-patient communication, and health literacy issues.
Improvements in preventive services, care for chronic conditions, and access to care have led to a reduction and in some cases elimination of disparities in access to and receipt of care for some minority populations in areas such as receipt of mammography, timing of antibiotics, counseling for smoking cessation, and pediatric vision care. On the other hand, disparities in care continue to be a problem for some conditions and populations. For example, blacks, Asians, American Indians/Alaska Natives, and Hispanics continue to lag behind whites in the percentage of the population over 50 who receive colon cancer screening, and this gap has widened in recent years.
Disparities also have increased for blacks and Hispanics, compared with whites, in the percentage of adults diagnosed with a major depressive disorder who received treatment for their depression in the 12 months following diagnosis.
Table of contents
- See also VitaminDWiki
- Improving Health Care for Minority Populations
- Researchers examine ways to increase breast cancer screening among Latinas.
- Physicians often rely on untrained individuals to help them discuss breast cancer treatment with limited English-proficient women.
- Racial disparities seen in receipt of chemotherapy among older women with breast cancer.
- Geographic clustering of late-stage breast cancer cases can help target interventions to increase mammography use.
- Less effective treatment and lower socioeconomic status may account for disparities in breast cancer survival.
- Tracking system greatly reduces racial disparities in receipt of adjuvant therapies among women with breast cancer.
- Study finds disparities in receipt of chemotherapy following ovarian cancer surgery.
- Some Latinas have higher rates of cervical cancer than white women.
- Several barriers to followup of an abnormal Pap smear may be encountered by Latinas.
- Elderly women, particularly black and Hispanic women, feel lifelong cervical cancer screening is important.
- Lack of physician trust may partly explain black/white differences in prostate cancer mortality rates.
- Researchers find that blacks have higher rates of pituitary adenoma than other ethnic groups.
- Colorectal cancer survival rates vary by race.
- Blacks have higher lung cancer mortality rates than whites.
- More whites than blacks are diagnosed with non-Hodgkin lymphoma, but blacks are more likely to die from it.
- Among American Indians, perceived cancer risk is associated with self-reportedfamily history of cancer.
- Men and blacks often are not aware of cancer screening benefits.
- Racial disparities in access to specialized cancer care vary by place of residence.
- Among people with melanoma, neighborhood socioeconomic factors affect prognosis.
- Race influences participation of companions in cancer consultations.
- Cardiovascular Disease
- Blacks who receive heart transplants have poorer survival than patients of other races.
- Racial disparities found in the use of statins and/or aspirin to prevent cardiovascular disease.
- Increasing access to coronary angiography led to a reduction in racial disparities in New Jersey.
- Disparities persist in access to specialists for patients with cardiovascular disease.
- Better short-term survival of blacks with heart failure correlates with less severe illness at hospital admission.
- Nurse-led disease management for heart failure is cost effective in ethnically diverse urban areas.
- Female and black stroke patients are less likely to receive preventive care to avoid further strokes.
- Care for the Elderly/Long-Term Care
- Caring for older family members is especially challenging for Korean Americans.
- Greater functional disability among older blacks and Latinos may be due in part to disparities in treatment and care quality.
- Racial disparities in care for the elderly persisted and even worsened for some procedures in the late 1990s.
- Chronic Illness
- Viewing patient stories seems to help black patients with hypertension manage their blood pressure.
- Control of high blood pressure can be difficult for blacks and Mexican Americans.
- Knowledge test validated for Korean Americans with hypertension. Researchers developed the High Blood
- Study finds low rates of racial/ethnic discrimination by health care providers caring for diabetes patients.
- Diabetes testing is declining among poor, minority, and inner-city adults.
- Health information. technology may be instrumental in decreasing disparities among people with diabetes.
- Few diabetes education programs serving American Indians and Alaska Natives meet national standards.
- Use of a uniform treatment algorithm eliminates racial disparities in blood sugar control.
- Low-income city-dwelling adults with high blood pressure are reasonably knowledgeable about their condition.
- Underresourced clinics that treat medically complex patients may partly explain poor chronic disease outcomes among minorities.
- Low health literacy and cultural differences affect screening and management of chronic disease.
- New program helps physicians teach patients how to correctly use asthma inhalers.
- More stress means worse asthma in inner-city adults.
- Study finds racial/ethnic variation in parental perceptions of their children's asthma.
- Many patients with sickle cell disease self-discharge from the hospital.
- Certain socioeconomic factors increase parental nonadherence to recommendations for managing sickle cell disease.
- Adult drug for sickle cell anemia may be safe for children.
- Formal and informal social support networks enhance management of HIV disease.
- Treatment of hepatitis C virus infection is less likely for blacks and those coinfected with HIV.
- Sociodemographic factors may predict early discontinuation of HIV therapy.
- Emergency Care/Hospitalization
- Researchers examine trends in hospitalization for children with Kawasaki syndrome.
- Minority children with asthma often use emergency departments (EDs) for care.
- Black children are more likely than white children to be hospitalized for a ruptured appendix.
- Blacks are less likely than whites to have surgery performed by high-volume surgeons and hospitals.
- Researchers call for increased use of professional interpreters in hospitals.
- Hospitalization rates for HIV infection have declined, but disparities still exist.
- Health Care Access, Costs, and Insurance
- Being foreign-born negatively affects access to care.
- Many U.S.-Mexico border residents "cross over" to obtain health care services.
- Enrollment in Medicare Advantage plans reduces disparities in primary care quality in three States.
- Americans, especially blacks, spend substantial periods of time uninsured.
- Some minority patients have difficulty accessing care provided by community health centers.
- Asian Americans enrolled in traditional fee-for-service Medicare receive fewer needed services than white patients.
- HIV care sites serving a large proportion of blacks and Hispanics may be difficult to access for all patients.
- Black and Hispanic Medicare patients often wait longer than white patients for surgery after hip fracture.
- Disparities in outpatient care and expenditures have widenedfor Hispanics but not for blacks.
- Minority children are half as likely as white children to receive specialized therapies.
- More blacks than whites have trouble affording their prescription medicines.
- Immigrants use fewer preventive services than U.S. natives.
- Hispanics enrolled in Medicare managed care plans are less positive than whites about their care experiences.
- Researchers examine the effects of various factors on children's health insurance coverage.
- Geographic information system may pinpoint areas where increased primary care is needed.
- Some minority patients voice concerns about using telemedicine to expand access to care.
- Mental/Behavioral Health
- Research finds a link between PTSD and elevated blood sugar in low income minorities.
- Among adolescents, whites are much more likely than blacks or Hispanics to use antidepressants.
- Less-accultured Latinos use fewer mental health services than others.
- Blacks and whites spend about the same amount of time in office visits with psychiatrists.
- Intervention may improve access to depression care for minority youths.
- Asian Americans resist using mental health services.
- Blacks and Hispanics are less likely than whites to seek treatment for mental health problems.
- Racial disparities affect physician-patient communication about mental health problems.
- Certain types of therapy are more effective for minority youth with psychosocial problems.
- Underserved blacks and Hispanics with depression often use alternative medicine for their symptoms.
- Preventive Services
- Quality of Care/Patient Safety
- Efforts to improve quality may not always reduce racial/ethnic disparities.
- Many black mothers are skeptical about the relationship between infant sleep position and SIDS.
- Having a strong social network plays a critical role in health status.
- Certain hospitalized patients are at increased risk for an adverse event.
- Black Medicare enrollees have more problems accessing care than white enrollees.
- Study compares trends in disparities over time.
- Payers and policymakers can incorporate disparity reduction goals into pay-for-performance strategies.
- AHRQ tool helps English- and Spanish-speaking consumers reduce medication errors.
- Blacks are more likely than members of other racial/ethnic groups to take part in medical decisionmaking.
- Medication adherence improves when patients are treated by providers of the same race.
- Doctor/patient communication style differs between white and Hispanic HIV patients.
- Report examines the effects of race/ethnicity and insurance status/income on quality of care for children.
- Pediatricians show less implicit race bias than others.
- Hispanics tend to give more positive ratings of care than whites.
- Enhancing cultural competence of clinicians and clinics may reduce care disparities.
- Reproductive Health and Birth Outcomes
- Perceived lower social standing is linked to unplanned pregnancies.
- Researchers find a link between race/ethnicity and risk for gestational diabetes.
- Study identifies ways to enhance prenatal care in underresourced settings.
- One-fifth of mothers do not receive recommended corticosteroids before delivery of premature infants.
- Stress and anxiety in pregnant black women contribute to low birthweight babies.
- Black women's choice of hospital to give birth may contribute to racial disparities in neonatal deaths.
- Most pregnant Latinas do not receive recommended screening for intimate partner violence.
- Pregnant Latinas who experience intimate partner violence often suffer from depression.
- Gene-environment interactions may explain the black/white disparities in preterm birth and infant mortality.
- Requiring proof of citizenship cut participation in Oregon's Medicaid family planning program.
- Advantage of high survival rates among Iow-weight black infants has diminished.
- Additional Studies
- Using pedometers to set activity goals increases physical activity among native elders.
- Study compares treatments to overcome phobia in Asian Americans.
- Twenty-seven percent of elementary school children living in Puerto Rico are obese.
- Race is one ofseveral factors in the Nation's epidemic of childhood obesity.
- Extrapulmonary TB occurs most often in black men.
- MRSA infections have increased among American Indian/Alaska Native individuals.
- Poor blacks have the worst long-term outcomes from work-related back pain.
- Differences in socioeconomic status in childhood correlate with racial differences in disability in adulthood.
- Perceived racism among black women is linked to socioeconomic position.
- Older Mexican American men are more accepting than others of physician-assisted suicide.
- Minority pediatricians are more likely than white pediatricians to care for minority children.
- Researchers examine patients' general attitudes toward doctors' race and ethnicity.
- Health literacy test found validfor both English- and Spanish-speaking individuals.
- CAHPS survey instrument developed in collaboration with Choctaw Nation Health Services program.
- Using a list of common surnames can help improve estimates of race/ethnicity in patient data.
- Researchers can safely omit race and ethnicity from cesarean rate risk-adjustment models.
- Researchers examine risk of workplace injury and how racial/ethnic disparities in risk change over time.
- Study results in culturally appropriate survey instruments for use with Hmong Americans.
- National Healthcare Quality and Disparities Reports
- For More Information
Improving Health Care for Minority Populations
The Agency for Healthcare Research and Quality supports extramural and intramural research on a broad range of topics related to health care quality and safety, effectiveness and outcomes, evidence-based medicine, health care delivery, and the costs and financing of health care. AHRQ also supports targeted research on health care for specific priority populations, including minorities. Additional resources and more detailed information can be found by visiting the AHRQ Web site at www.ahrq.gov.
This program brief summarizes findings from AHRQ-supported research on minority health reported in the literature and/or published by AHRQ from 2008 through mid-2012. Items marked with an asterisk (*) are available from AHRQ. See the last page of this brief for more information.
Researchers examine ways to increase breast cancer screening among Latinas.
This study evaluated two interventions to address the underuse of mammography and breast self-exam among Latinas:
(1) participation in focus groups to assess knowledge about breast cancer and identify barriers to screening and
(2) participation in discussion groups, including an animated video on breast self-exam plus training in the technique using latex models. Both interventions were cost effective and successful in increasing the women's knowledge and screening behaviors. Calderon, Bazargan, and Sangasubana, J Health Care Poor Underserved 21:76-90, 2010 (AHRQ grant HS14022).
Physicians often rely on untrained individuals to help them discuss breast cancer treatment with limited English-proficient women.
Researchers surveyed 348 physicians about their use and availability of trained interpreters when counseling limited English-proficient women with breast cancer. Nearly all of the physicians had treated patients with limited English proficiency in the preceding 12 months, and fewer than half reported good availability of trained medical interpreters or telephone language interpretation services. Instead, they used bilingual staff not specifically trained in medical interpretation and patients' family members or friends. This was particularly true for physicians in solo practice or single-specialty medical groups. Rose, Tisnado, Malin, et al., Health Serv Res 45(1):172-194, 2010 (Interagency agreement AHRQ/NCI).
Racial disparities seen in receipt of chemotherapy among older women with breast cancer.
The researchers examined 2002 data on 14,177 white women and 1,277 black women aged 65 and older who were diagnosed with operable stage II or IIIA breast cancer with positive lymph nodes. For the 65-69 age group, 66 percent of white women received chemotherapy within 6 months of diagnosis, compared with 56 percent of black women. This racial disparity diminished with advancing age; after age 74, there were no differences between white women and black women in receipt of chemotherapy. Bhargava and Du, Cancer 115(13):2999-3008, 2009 (AHRQ grant HS16743).
Geographic clustering of late-stage breast cancer cases can help target interventions to increase mammography use.
A telephone survey conducted between March 2004 and June 2006 in the St. Louis, MO area revealed that more black than white women had obtained mammograms during that time. St. Louis is an area known to have high rates of late-stage breast cancer diagnosis. The researchers suggest that such geographic clustering might be used to target specific populations and areas for interventions (e.g., traveling mammography vans, flexible clinic hours) that could increase mammography use. Lian, Jeffe, Schootman, J Urban Health 85(5):677-692, 2008 (AHRQ grant HS14095).
Less effective treatment and lower socioeconomic status may account for disparities in breast cancer survival.
Researchers studied more than 35,000 Medicare-insured women with early-stage breast cancer for as long as 11 years and found that black women were more likely than white women to live in the poorest census tract quartiles. Also, more black women (15.7 percent) received breast-conserving surgery without followup radiation therapy than white women (12.4 percent), Hispanic women (11 percent), and Asian women (7.9 percent). Since the recommended therapy for early-stage breast cancer is breast-conserving surgery plus radiation, these treatment differences could have contributed to disparities in survival, suggest the researchers. Du, Fang, and Meyer, Am J Clin Oncol 31(2): 125-132, 2008 (AHRQ grant HS16743).
Tracking system greatly reduces racial disparities in receipt of adjuvant therapies among women with breast cancer.
These researchers developed a tracking system to follow women with breast cancer who had seen a surgeon so that they could be contacted in the event they did not connect with an oncologist. The researchers compared the treatment of 639 women who were seen at six New York City hospitals before implementation of the tracking system with 300 women who were seen while the tracking system was in use. Rates of oncology consultations, chemotherapy use, and hormonal therapy were higher for all women, particularly minority women, after the tracking system was in place. For example, underuse of radiotherapy declined from 23 to 10 percent, underuse of chemotherapy decreased from 26 to 6 percent, and underuse of hormone therapy decreased from 27 to 11 percent among black and Hispanic women. Bickell, Shastri, Fei, et al., J Natl Cancer Inst 100(23):1717-1723, 2008 (AHRQ grant HS10859).
Study finds disparities in receipt of chemotherapy following ovarian cancer surgery.
Clinical guidelines have recommended since 1994 that all women diagnosed with ovarian cancer stage IC-IV or higher receive chemotherapy following surgery to remove the cancer. This study of more than 4,000 black and white women aged 65 or older who were diagnosed with stage IC-IV ovarian cancer found that white women were more likely than black women to receive chemotherapy after surgery (65 percent vs. 50 percent, respectively), although survival rates did not differ between the two groups of women. Women with higher socioeconomic status (SES) had increased use of both surgery and chemotherapy, and women in the lowest quartile of SES were more likely to die than those in the highest quartile of SES. Du, Sun, Milam, et al., Int J Gynecol Cancer 18(4):660-669, 2008 (AHRQ grant HS16743).
Some Latinas have higher rates of cervical cancer than white women.
According to this study, women of Mexican descent born in the United States are at higher risk for contracting the human papillomavirus (HPV) that causes cervical cancer than white women and foreign-born Latinas. Indeed, those who have acculturated— i.e., they think, speak, and read English at home or with friends—are more likely than less acculturated Latinas to contract HPV and cervical cancer. Kepka, Coronado, Rodriguez, and Thompson, Prev Med 51(2):182-184, 2010 (AHRQ HS13853).
Several barriers to followup of an abnormal Pap smear may be encountered by Latinas.
In this study involving 40 Latinas who had an abnormal Pap smear, researchers identified four primary barriers to followup with colposcopy: anxiety or fear of the test, difficulty in scheduling the test around work and/ or child care commitments, poor communication/language difficulties (30 women spoke Spanish only), and concern about pain. Percac-Lima, Aldrich, Gamba, et al., J Gen Intern Med25(11):1198-1204, 2010 (AHRQ HS19161). See also National Healthcare Disparities Report 2008, available at www.ahrg.gov/qual/qrdr08.htm (Intramural).
Elderly women, particularly black and Hispanic women, feel lifelong cervical cancer screening is important.
Researchers interviewed 199 women aged 65 or older about their preferences for cervical cancer screening. All of the women had received regular cervical cancer screenings, and none had undergone a hysterectomy. More than half of the women (58 percent) felt that lifelong screening was either important or very important. Compared with Asian and white women, Latinas and black women were more likely to hold strongly to this belief. Only 20 percent of women said they had talked with their physicians about ending screening. Sawaya, Iwaoka-Scott, Kim, et al., Am J Obstet Gynecol 200(1):40.el-40.e7, 2009 (AHRQ grant HS10856).
Lack of physician trust may partly explain black/white differences in prostate cancer mortality rates.
Prostate cancer mortality is more than twice as high for black men as for white men in the United States, and lack of physician trust may play a role in this disparity. More than 1,300 interviews were conducted with 474 men to examine the relationship between physician trust and health care access among black and white prostate cancer patients. Results showed that black men generally had lower levels of trust in their physicians than white men, particularly black men who reported having failed to seek medically necessary care. Do, Carpenter, Spain, et al., Cancer Causes Control 21:31-40, 2010 (AHRQ grant HS1085l).
Researchers find that blacks have higher rates of pituitary adenoma than other ethnic groups.
An analysis of 2004-2007 data covering nearly 26 percent of the U.S. population identified 8,276 cases of pituitary adenoma (tumors on the pituitary gland that are usually benign). The highest age-adjusted incidence of pituitary adenoma was found for blacks (4.4 cases per 100,000), and the lowest was found for American Indians/Alaska Natives (1.9 cases per 100,000). Blacks were more likely than other groups to have their pituitary adenomas diagnosed through x-ray alone (no microscopic confirmation), and even though their tumors were slightly larger than those found in whites, blacks had lower rates of surgical treatment than other groups. McDowell, Wallace, Carnahan, et al., Pituitary14:23-30, 2011 (AHRQ grant HS16094).
Colorectal cancer survival rates vary by race.
According to this study, blacks have lower colorectal cancer survival rates than whites, Asians, and Hispanics. Asians have a lower risk of dying than whites, while mortality rates for Hispanics and whites are similar. The mortality differences between blacks and whites seen in this study were associated mostly with socioeconomic status (5 percent), tumor characteristics (3 percent), treatment (2 percent), and coexisting illness (2 percent). The researchers note that poor survival among blacks may also be related to biologic features that contribute to aggressive tumor behavior or to genetic abnormalities that may have an impact on response to therapy. White, Vernon, Franzini, and Du, Cancer 116:46224631, 2010. See also Du and Liu, J Health Care Poor Underserved 21:913930, 2010; White, Liu, Xia, et al.,
Cancer 113(12):3400-3409, 2008 (AHRQ grant HS16743); Bazargan, Ani, Bazargan-Hejazi, et al., Patient Educ Counsel 76:240-247, 2009; and Ani, Bazargan, Bazargan-Hejazi, et al., Ethn Dis 18(2 Suppl 2):105-111, 2008 (AHRQ grant HS14022).
Blacks have higher lung cancer mortality rates than whites.
Lung cancer remains the leading cause of cancer-associated mortality, and blacks continue to have lower survival
rates than whites. This study found that compared with whites, blacks with non-small-cell lung cancer (NSCLC) had a 22 percent greater overall risk of dying from all causes during the various stages of NSCLC, and blacks with stage III or IV NSCLC were 24 percent more likely to die from lung cancer than whites. Receipt of standard stage-specific treatment was significantly associated with longer survival, and poor socioeconomic status was associated with a greater risk of dying. Hardy, Xia, Liu, et al., Cancer 115(20):4807-4818, 2009. See also Hardy, Liu, Xia, et al., Cancer 115:2199-2211, 2009 (AHRQ grant HS16743).
More whites than blacks are diagnosed with non-Hodgkin lymphoma, but blacks are more likely to die from it.
An estimated 63,000 elderly individuals are diagnosed with non-Hodgkin lymphoma (NHL) in the United States each year. Whites are more likely than other groups to be struck with the disease, but compared with blacks, they also are more likely to receive life-prolonging chemotherapy. In this study, blacks were significantly less likely than whites to receive chemotherapy (43.2 vs. 52.4 percent). Also, lower socioeconomic status, more common among the black patients studied, was significantly associated with a higher risk of dying. Wang, Burau, Fang, et al., Cancer 113(11):3231-3241, 2008 (AHRQ grant HS16743).
Among American Indians, perceived cancer risk is associated with self-reportedfamily history of cancer.
A random survey of 182 American Indian adults living on a Hopi reservation in Northeastern Arizona found that knowledge of cancer risk factors and attitudes about cancer prevention were not associated with the participants' perceived risk of cancer.
Only a family history of cancer was significantly associated with perceived risk in this population. Gonzales, Ton, Garroutte, et al., Ethn Dis 20:458-462, 2010 (AHRQ grant HS10854).
Men and blacks often are not aware of cancer screening benefits.
Characteristics like sex, race, and education level are associated with how well patients understand the benefits of cancer screening. For this study, researchers surveyed a diverse group of 467 women and 257 men aged 50 and older from seven primary care practices in North Carolina to elicit their feelings about various cancer screening tests. About half of those surveyed were unsure of what to do about cancer screening, although most knew about its benefits. Men were only about half as likely as women to know the benefits of cancer screening, and blacks were much more likely than whites not to know about the benefits. Gourlay, Lewis, Preisser, et al., Fam Med 42(6):421-427, 2010 (AHRQ grant HS13521). See also Carpenter, Howard, Taylor, et al., Cancer Causes Control 21:1071-1080, 2010 (AHRQ grant HS13353) and Pagan, Su, Li, et al., Am J Prevent Med37(6):524-530, 2009 (AHRQ grant HS17003).
Racial disparities in access to specialized cancer care vary by place of residence.
Using 2000 census data, researchers calculated the travel times to specialized cancer centers and oncologists for all ZIP code areas and found that rural blacks have the longest travel times to National Cancer Institute centers of care. Rural blacks were only 42 percent as likely as rural whites to seek care at these national centers. Onega, Duell, Shi, et al., J Rural Health 26:12-19, 2010. See also Onega, Duell, Shi, et al., Cancer 112(4):909-918, 2008 (AHRQ grant T32 HS00070); and Outcomes of Community Health Worker Interventions, Evidence Report/ Technology Assessment No. 181, available at www.ahrg.gov/downloads/pub/evidence/pdf/comhealthwork/comhwork.pdf.
Among people with melanoma, neighborhood socioeconomic factors affect prognosis.
According to this study, melanoma prognosis is significantly associated with neighborhood racial heterogeneity, education, and income. Patients who live in predominantly white, wealthy, and highly educated communities are less likely to have a poor prognosis compared with those living in less advantaged communities. Eide, Weinstock, and Clark, J Health Care Poor Underserved 20:227-245, 2009 (AHRQ grant T32 HS00011).
Race influences participation of companions in cancer consultations.
Companions can play an important role in meetings between newly diagnosed cancer patients and their clinicians. For this study involving newly diagnosed lung cancer patients, researchers recorded and analyzed conversations between clinicians from a medical center's oncology or thoracic surgery clinic and the patients and their companions (if applicable). They found that the companions of black patients were less active participants in the conversation compared with the companions of white patients. Companions were more likely to be active participants when the physician's communication emphasized partnership-building and supportive talk and when the lung cancer diagnosis had been made before the visit. Street and Gordon, Psychooncology17:244-251, 2008 (AHRQ grant HS10876).
Blacks who receive heart transplants have poorer survival than patients of other races.
Researchers analyzed outcomes data for nearly 40,000 patients who underwent heart transplants over a 22-year period (1987-2009). Almost 5,000 of the patients were black, and they had a 34 percent higher risk of transplant-related death than the nearly 31,000 white patients. Transplant recipients of other races (2,118 Hispanics, 967 Asians, and patients from other non-black groups) did not differ from whites in adjusted risk of transplant-related death. Liu, Bhattacharaya, Weill, et al., Circulation 123(15):1642-1649 (AHRQ grant HS19181).
Racial disparities found in the use of statins and/or aspirin to prevent cardiovascular disease.
According to this study involving adults at high risk of cardiovascular disease (CVD), blacks are less likely than whites to use statins (38 percent vs. 50 percent, respectively) or aspirin (29 percent vs. 44 percent) to prevent CVD. The researchers note that these disparities in the use of CVD medications may contribute to the documented disparities between blacks and whites in CVD outcomes. Statin use did not differ between whites and Hispanics, but Hispanics were less likely than whites to use aspirin. Qato, Lindau, Conti, et al., Pharmacoepidemiol Drug Saf19:834-842, 2010 (AHRQ grant HS13599).
Increasing access to coronary angiography led to a reduction in racial disparities in New Jersey.
Researchers examined the effects of regulatory reforms in New Jersey between 1996 and 2003 and found that a doubling of angiography facilities closed the gap between blacks and whites in access to these services. Reducing this disparity was significant, since blacks are at higher risk for heart disease and have higher cardiac death rates than whites, note the researchers. Cantor, Delia, Tiedemann, et al., Health Af28(5):1521-1531, 2009 (AHRQ grant HS14191).
Disparities persist in access to specialists for patients with cardiovascular disease.
Researchers examined medical records for 9,761 adults with coronary artery disease (CAD) or congestive heart failure (CHF) at primary care practices affiliated with two academic medical centers from 2000 to 2005. They found that 79.6 percent of patients with CAD and 90.3 percent of patients with CHF had a cardiology consultation during that period. Men were more likely than women to be referred to a cardiologist, and patients being treated at community health centers were less likely than those at hospital-based practices to receive a consultation. Blacks were more likely than whites to obtain an initial consultation, but those with CHF had fewer followup consultations than whites, which may reflect weaker relationships with their specialists, note the researchers. Cook, Ayanian, Orav, and Hicks, Circulation 119:2463-2470, 2009 (AHRQ grant T32 HS00020).
Better short-term survival of blacks with heart failure correlates with less severe illness at hospital admission.
Researchers analyzed data on 1,408 blacks and 7,260 whites who were admitted to the hospital from the emergency department (ED) during 2003 and 2004 and discharged with a diagnosis of heart failure. Overall, black patients were younger than white patients (65.8 years vs. 77.4 years) and were much more likely than white patients to be assigned to the lowest risk class using one of three prediction rules. Two possible explanations for these findings are: (1) blacks are less likely than whites to have a usual source of care and may be more likely to seek initial care for heart failure in the ED; and (2) better access to primary care for whites may paradoxically result in greater illness severity when they do arrive at the ED, since they are more likely to visit the ED after failure of initial outpatient treatment. Auble, Hsieh, and Yealy, Am Heart J 157(2):306-311, 2009 (AHRQ grant HS10888).
Nurse-led disease management for heart failure is cost effective in ethnically diverse urban areas.
Researchers randomized 406 low-income patients with heart failure to either usual care or a nurse-led disease management program. All of the patients were from the Harlem neighborhood of New York City, and most were black or Hispanic. During the year-long program, patients in the intervention group received regular telephone calls and dietary instruction. Compared with patients in the usual care group, the nurse-led patients maintained better physical functioning and had higher quality-of-life scores. The per-patient cost of the nurse-led intervention was $2,177, which was offset by the $2,378 in lower hospitalization costs per person. Hebert, Sisk, Wang, et al., Ann Intern Med 149:540-548, 2008 (AHRQ grant HSI0402).
Female and black stroke patients are less likely to receive preventive care to avoid further strokes.
One in three stroke survivors will suffer another stroke within 5 years, but there are measures clinicians can take to reduce the risk of another stroke. According to this study of 501 patients hospitalized for acute ischemic stroke, 54 percent of whites, 62 percent of Hispanics, and 77 percent of blacks received incomplete inpatient evaluations. Similarly, 66 percent of women had incomplete inpatient evaluations, compared with 54 percent of men. In addition, 40 percent of whites, 43 percent of Hispanics, and 59 percent of blacks received inadequate discharge regimens of anticoagulant, antihypertensive, and lipid-lowering medications. Blacks and Hispanics are at greater risk for recurrent strokes than whites. Improving delivery of these effective interventions will reduce recurrent stroke risk and may reduce stroke risk disparities among minorities, conclude the researchers. Tuhrim, Cooperman, Rojas, et al., J Stroke Cerebrovasc Dis 17(4):226-234, 2008
(AHRQ grant HS10859).
Care for the Elderly/Long-Term Care
Caring for older family members is especially challenging for Korean Americans.
The researchers conducted eight focus groups with first-generation Korean American adults who were living with and/or providing care to a Korean American relative or nonrelative aged 60 or older. Focus group participants expressed a strong sense of duty to care for ill or frail family members, thereby upholding the traditional value of daughter/son devotion. This duty often competed with other life priorities within immigrant life, such as working extremely long hours and communication difficulties. All of the caregivers were ambivalent about using outside, formal services, which they viewed as a last resort. Han, Choi, Kim, et al., JAdv Nurs 63(5):517-526, 2008 (AHRQ grant HS13779).
Greater functional disability among older blacks and Latinos may be due in part to disparities in treatment and care quality.
This study of community-dwelling adults aged 50 and older found that blacks and Latinos with physician visits and hospitalizations were significantly less able than same-aged whites to carry out activities of daily living. In addition, many of the blacks and Latinos in this survey had more mobility limitations than whites. Other predisposing factors (e.g., age and sex, chronic illness, and economic access to care) did not account for the greater disability among blacks and Latinos. These findings suggest that improving economic access to care may not be enough to guarantee equal access to high-quality care. Bowen and Gonzalez, Gerontologist 48(5):659-667, 2008 (AHRQ grant HS13819).
Racial disparities in care for the elderly persisted and even worsened for some procedures in the late 1990s.
Researchers analyzed discharge data for New York and Pennsylvania hospitals for elderly patients undergoing three referral-sensitive hospital procedures during 1997 and 2001—coronary angiography, heart bypass surgery, and hip/joint replacement, all high-technology procedures that generally require referral to a specialist. Elderly blacks were 37 percent less likely than elderly whites to have received angioplasty in 1997. This disparity had widened considerably by 2001, to 48 percent. Disparities in hip/joint replacement among other races also increased over time relative to whites. Basu and Mobley, Med Care Res Rev 65(5):617-637, 2008 (AHRQ Publication No. 08-R074)* (Intramural).
Viewing patient stories seems to help black patients with hypertension manage their blood pressure.
This study found that watching story segments of patients talking about high blood pressure helped black men and women with hypertension make substantial improvements in their own blood pressure readings. The study involved 299 blacks with hypertension who were recruited from an inner city clinic in the South; 147 of the patients were assigned to the storytelling intervention, and the other 152 were assigned to the usual-care group. Those in the intervention group showed a reduction in blood pressure that persisted through the 9-month followup period. Houston, Allison, Sussman, et al., Ann Intern Med 154(2):77-84, 2011 (AHRQ grant HS19353).
Control of high blood pressure can be difficult for blacks and Mexican Americans.
Despite adherence to treatment and lifestyle changes, high blood pressure control is often elusive for blacks and Mexican Americans, according to this study of nearly 5,400 adults with hypertension. Blacks and Mexican Americans were twice as likely as whites to report following advice to exercise, quit smoking, restrict alcohol, and reduce stress. Also, blacks were much more likely to report salt restriction and attempts to lose weight. Despite adherence to medication (which was similar for all three groups) and lifestyle modification, both blacks and Mexican Americans were 40 percent and 50 percent, respectively, more likely than whites to continue to suffer from uncontrolled hypertension. Natarajan, Santa Ana, Liao, et al., Ann Epidemiol 19:172-179, 2009 (AHRQ grant HS10871).
Knowledge test validated for Korean Americans with hypertension. Researchers developed the High Blood
Pressure Knowledge Test and assessed its utility, reliability, and validity in a group of Korean Americans. Results showed that the test is sensitive to differences in blood pressure control status and should provide a reliable, standardized measure of high blood pressure with wide relevance. Han, Chan, Song, et al., J Clin Hypertension 13(10):750-757, 2011. See also Lee, Han, Song, et al., Int JNurs Stud 47(4):411-417, 2010; Han, Kim, Kim, et al., Patient Educ Counsel 80:130-134, 2010; and Kim, Han, Song. et al., J Clin Hypertension 12(4):253-260, 2010 (AHRQ grant HS13160).
Study finds low rates of racial/ethnic discrimination by health care providers caring for diabetes patients.
Discrimination has been suggested as one potential explanation for racial/ethnic disparities in health and health care. However, this study of 18,000 patients receiving care in a large group plan in northern California found that just 3 percent of members had reported discrimination from doctors or other providers, compared with 20 percent who reported such discrimination in everyday life. All racial/ethnic minority groups reported discrimination more frequently than whites, with blacks reporting general discrimination most frequently, and Filipinos reporting health care provider
discrimination most often. Lyles, Karter, Young, et al., J Health Care Poor Underserved 22:211-225, 2011 (AHRQ grant HS13853).
Diabetes testing is declining among poor, minority, and inner-city adults.
According to data presented in the 2010 National Healthcare Disparities Report, the proportion of poor adults aged 40 and older with diabetes that had their blood sugar, eyes, and feet examined at least once a year dropped from 39 percent to 23 percent between 2002 and 2007. Blacks experienced an 11 percent drop in testing, from 43 to 32 percent, while the proportion of Hispanics who had all three exams fell from 34 to 27 percent over the same period. The decline was smallest among whites at 4 percent (from 43 to 39 percent). Available at www.ahrg.gov/qual/qrdr10.htm (Intramural).
Health information. technology may be instrumental in decreasing disparities among people with diabetes.
This literature review included 18 articles published between 2006 and 2009 on the effectiveness of health care interventions using health information technology to improve diabetes process of care and intermediate diabetes outcomes in black and Hispanic patients in underresourced settings. Baig, Wilkes, Davis, et al., Med Care Res Rev 67(5 Suppl):163S-197S, 2010. See also Lu, Kotelchuck, Hogan, et al., Med Care Res Rev 67(5):1985-2305, 2010 (AHRQ contract P233200900421P).
Few diabetes education programs serving American Indians and Alaska Natives meet national standards.
American Indians and Alaska Natives have diabetes rates that are two to three times as high as the general population, and they are four times as likely to die from the disease. Thus, diabetes education is particularly important for these individuals to help them learn to self-manage their disease. According to this study, few diabetes education programs funded by the Indian Health Service met national standards in 2001. Programs were assessed against three levels of care, and only 9 of 86 programs achieved level 2 recognition. Since that time, with increased funding toward staff and training, the number of recognized programs grew to 37 in 2009. Roubideaux, Noonan, Goldberg, et al., Am J Public Health 98(11):2079-2084, 2008 (AHRQ grant HS10854).
Use of a uniform treatment algorithm eliminates racial disparities in blood sugar control.
According to this study, differences between blacks and whites in glycemic levels disappear in care settings where treatment is uniform, immediate care is facilitated, and medication is aggressively managed. Patients with type 2 diabetes (3,324 blacks, 218 whites) all made initial and 1-year followup visits; a subset of patients had an additional followup visit at 2 years. Patient adherence to treatment, number of visits, and provider behavior were similar for both groups. Initially, glycemic levels were higher in black patients than in white patients; at 1 year, the difference in glycemic levels had narrowed but remained significant. Among those who returned for a 2-year visit, (1,691 blacks, 114 whites), glycemic levels were no longer different. Rhee, Ziemer, Caudle, et al., Diabetes Educ 34(8):655-663, 2008 (AHRQ grant HS07922).
Low-income city-dwelling adults with high blood pressure are reasonably knowledgeable about their condition.
This study of predominantly low-income black women with hypertension found that nearly twothirds (65 percent) of them were fairly knowledgeable about their condition. Those with less knowledge tended to be at least 60 years of age, have less than a high school education, or be recently diagnosed with the condition. Individuals who were uncomfortable asking questions of their doctors also were less knowledgeable. Nearly one-fourth of the patients did not know that high blood pressure can cause kidney problems, despite the prevalence of kidney problems among blacks with hypertension. The study involved 296 adults being cared for at one urban clinic. Sanne, Muntner, Kawasaki, et al., Ethn Dis 18:42-47, 2008 (AHRQ grant HS11834).
Underresourced clinics that treat medically complex patients may partly explain poor chronic disease outcomes among minorities.
Primary care clinics that serve minority patients have less access to medical resources, a chaotic work environment, and more medically challenging patients, compared with clinics that serve predominantly white patients, according to this study. The researchers compared data from 27 clinics with at least 30 percent minority patients with data from 69 clinics with less than 30 percent minority patients. Varkey, Manwell, Williams, et al., Arch Intern Med 169(3):243-250, 2009 (AHRQ grant HS11955).
Low health literacy and cultural differences affect screening and management of chronic disease.
The researchers examined the impact of cultural differences and low health literacy on chronic disease outcomes and the use of preventive screening tests and found that many racial/ethnic groups lack an understanding of the idea of chronic disease. For example, the stigma associated with non-normative sexual behavior may keep unmarried Latinas from seeking out Pap smears. The researchers call for programs to address cultural and linguistic barriers in primary care and prevention settings. Shaw, Huebner, Armin, et al., J Immigr Minor Health 11:460-467, 2009 (AHRQ grant HS14086). See also Schillinger, Hammer, Wang, et al., Health Educ Behav 35:664-682, 2008 (AHRQ grant HS14864).
New program helps physicians teach patients how to correctly use asthma inhalers.
Asthma is a chronic illness that disproportionately affects minorities living in major urban areas. Critical to asthma self-management is patients' ability to use inhalers properly, but factors such as low patient health literacy and poor clinician knowledge of new inhalers and their use can make patient education difficult. The Chicago Breathe Project is an intervention designed to improve education for resident physicians on new inhalers and inhaler techniques and ways to assess their use during patient encounters. According to the researchers, the Chicago Breathe Project can be easily replicated in other urban areas to benefit minority communities affected by asthma. Press, Pincavage, Pappalardo, et al., J Natl Med Assoc 102(7):548-555, 2010 (AHRQ grant HS16967).
More stress means worse asthma in inner-city adults.
This study found a direct link between an individual's level of stress and the severity of their asthma. Those who perceived higher stress levels were more likely to have increased asthma-related problems compared with those who reported lower stress levels. The study's findings are based on encounters with 326 inner-city residents with asthma; most were either black or Hispanic and of low socioeconomic status. They also had various conditions in addition to asthma, including hypertension (47 percent) and diabetes (25 percent). Wisnivesky, Lorenzo, Feldman, et al., J Asthma 47:100-104, 2010. See also Ponieman, Wisnivesky, Leventhal, et al., Ann Allergy Asthma Immunol 103:38-42, 2009; Wisnivesky, Kaltan, Evans, et al., Med Care 47(2):243-249, 2009; and Wisnivesky, Lorenzo, Lyn-Cook, et al., Ann Allergy Asthma Immunol 101:264-270, 2008 (AHRQ grant HS13312).
Study finds racial/ethnic variation in parental perceptions of their children's asthma.
Researchers interviewed parents of 739 children with persistent asthma in a Medicaid health plan in Massachusetts. Overall, 75 percent of parents believed their children could be symptom-free most of the time (75 percent Latino, 84 percent black, and 89 percent white). Also, 43 percent of Latino parents, 44 percent of black parents, and 55 percent of white parents said their children should have no emergency room visits or hospitalizations for asthma. Black (18 percent) and Latino (23 percent) parents were more likely than white parents (8 percent) to have competing family priorities "all of the time" or "most of the time" in addition to their child's asthma, even after adjusting for income, education, insurance, and other factors. Wu, Smith, Bokhour, et al., Ambul Pediatr 8(2):89-97, 2008 (AHRQ grant T32
Many patients with sickle cell disease self-discharge from the hospital.
This study found that many patients with sickle cell disease leave the hospital against medical advice, which can jeopardize their health. Those who were more distrustful of clinicians and those who reported difficulty in persuading medical staff about sickle cell pain were more likely to self-discharge from the hospital. Haywood, Lanzkron, Ratanawongsa, et al., JHosp Med 5:289-294, 2010 (AHRQ grant HS13903). See also Tanabe, Porter, Creary, et al., J Natl Med Assoc 102(11):1033-1041, 2010 (AHRQ grant T32 HS00078); Sobota, Graham, Heeney, et al., Am J HematoI 85(1):24-28, 2010 (AHRQ grant T32 HS00063); and Brousseau, Owens, Mosso, et al., JAMA 303(13):1288-1294, 2010 (AHRQ Publication No. 10-R060)* (Intramural).
Certain socioeconomic factors increase parental nonadherence to recommendations for managing sickle cell disease.
Infants with sickle cell disease are at greatly increased risk for pneumococcal infection. Treatment with penicillin has been shown to reduce the risk of infection by 64 percent, but this study found that 60 percent of Medicaid-enrolled infants with sickle cell disease did not receive an antibiotic prescription by the age of 12 weeks. Having one or more risk factors—being a single mother, maternal age younger than 20 years, maternal education less than 12 years, very low income, and urban residence—significantly increased nonadherence to recommended treatment. Warren, Arbogast, Dudley, et al., Arch Pediatr Adolesc Med 164(3):298-299, 2010 (AHRQ grant HS16974).
Adult drug for sickle cell anemia may be safe for children.
This review of published studies found that the medication hydroxyurea— which is approved for use in adults with sickle cell disease to prevent sudden, painful episodes—may also be useful and safe when taken by children with the disease. A panel of experts found that hydroxyurea did not cause growth delay in children ages 5 to 15, but because the drug affects the reproductive system of male mice, it may have an adverse effect on sperm production after puberty. Strouse, Lanzkron, Beach, et al., Pediatrics 122(6):1332-1342, 2008 (AHRQ contract 290-02-0018).
Formal and informal social support networks enhance management of HIV disease.
The advent of improved treatment for HIV infection has changed the nature of the disease from an acute illness to a chronic condition. This has increased the importance of HIV disease management, including regular medical appointments and consistent medication use. Through interviews with HIV-positive adults, this study found that formal support networks (professional support organizations) are critical for engagement in HIV-specific medical care, while informal networks (family, friends) are instrumental in emotional, household-related, and financial support. George, Garth, Wohl, et al., J Health Care Poor Underserved 20:1012-1032, 2009 (AHRQ grant HS14022).
Treatment of hepatitis C virus infection is less likely for blacks and those coinfected with HIV.
This study compared treatment of 241 patients with hepatitis C virus (HCV) infection and 158 patients with HCV
and HIV coinfection and found that HIV coinfection was an independent predictor of not receiving treatment for HCV. Blacks also were less likely than whites to receive treatment for HCV, most likely because of their reduced likelihood of achieving good treatment responses to HCV medications compared with whites. Butt, Tsevat, Leonard, et al., Int J Infect Dis 513:449455, 2009 (AHRQ grant HS13220).
Sociodemographic factors may predict early discontinuation of HIV therapy.
Antiretroviral therapy (ART) used to treat HIV infection can have severe and debilitating side effects (e.g., nausea, vomiting. diarrhea, dizziness, and intense dreams), yet long-term adherence is critical to halting disease progression. This study found that blacks and young people are more likely than others to stop taking their HIV medication early, and women are more likely than men to stop taking some ART drugs. These use patterns may be due to greater and more severe side effects related to genetic differences among blacks and/ or greater susceptibility to drug side effects among women, according to the researchers. Asad, Hulgan, Raffanti, et al., J Natl Med Assoc 100(12):1417-1424, 2008 (AHRQ grant HS10384).
Researchers examine trends in hospitalization for children with Kawasaki syndrome.
Kawasaki syndrome (KS) is a rare childhood disease affecting the blood vessels that occurs most often among children aged 5 or younger of Japanese or other Asian ancestry living in Hawaii and the continental United States. This study found that children younger than age 5 accounted for more than 83 percent of all Kawasaki-related hospitalizations, and that higher hospitalization rates were observed for boys, children from higher income families, and children with private insurance. Japanese children had the highest incidence per 100,000 population (210.5), followed by Native Hawaiian children (86.9), other Asian children (84.9), and Chinese children (83.2). Homan, Christensen, Belay, et al., Hawaii Med J 69:194-197, 2010. (AHRQ -Publication No. 11-R004).* See also Holman, Belay, Christensen, et al., Pediatr Inject Dis J 29(6):483-488 (AHRQ Publication No. 11-R074)* (Intramural).
Minority children with asthma often use emergency departments (EDs) for care.
Researchers analyzed 1996-2000 data on 982 children with asthma and found that black and Hispanic children received asthma care in the ED more often than white children, which is consistent with findings from earlier studies. The authors suggest that additional ED visits occur because these children often lack a usual source of care and do not have a plan in place to manage asthma at home when an attack occurs. Thus, improving care access and offering programs to teach caregiver skills to manage asthma may reduce ED visits. Kim, Kieckhefer, Greek, et al., Prev Chronic Dis, 6(1):Epub, 2009 (AHRQ grant HS13110).
Black children are more likely than white children to be hospitalized for a ruptured appendix.
According to an analysis of data from AHRQ, the hospital admission rate of black children for a ruptured appendix in 2006 was 365 per 1,000 admissions, compared with 276 per 1,000 admissions for white children. Hispanic children had the second highest rate, 344.5 per 1,000 admissions, followed by Asian and Pacific Island children at 329 per 1,000 admissions. See the 2009 National Healthcare Disparities Report, available at www.ahrq.gov/qual/nhdr09/nhdr09.pdf (Intramural).
Blacks are less likely than whites to have surgery performed by high-volume surgeons and hospitals.
Researchers examined data from New York City hospitals for 10 surgical procedures that have shown a direct relationship between volume and reduced short-term mortality. Examples include heart bypass surgery, total hip replacement, and certain cancer surgeries. For 9 of the 10 procedures, black patients were significantly less likely than whites to have their surgery performed by a high-volume surgeon or in a high-volume hospital. Asian and Hispanic patients also were more likely to have a less-experienced surgeon perform the procedure at a low-volume hospital. Epstein, Gray, and Schlesinger, Arch Surg 145(2):179-180, 2010. See also Gray, Schlesinger, Siegfried, and Horwitz, Inquiry 46:322-338 (AHRQ grant HS14074).
Researchers call for increased use of professional interpreters in hospitals.
This study examined the correlation between limited English proficiency and hospital readmission rates and found that Chinese and Spanish speakers were more likely to be readmitted to the hospital than English speakers. When compared directly with English-speaking Asians and Latinos, the higher readmission rates persisted for those who spoke only Chinese and Spanish. Among English speakers, blacks had the highest and Latinos the lowest readmission rates. Since only 14 percent of the non-English-speaking patients used professional staff
interpreters, the researchers cite the need to create a culture of professional interpreter use in hospitals. Karliner, Kim, Meltzer, and Auerbach, J Hosp Med 5:276-282, 2010 (AHrQ grants HS10597 and HS11416).
Hospitalization rates for HIV infection have declined, but disparities still exist.
The annual rate of hospitalizations for HIV infection has declined consistently over the past few years, yet blacks, women, those infected with HIV through IV drug use, and older individuals are still hospitalized more often than other patients with HIV. Patients covered by Medicare, Medicaid, or a combination of the two were much more likely to be hospitalized than patients with private insurance. Yehia, Fleishman, Hicks, et al., J Acquir Immune Defic Syndr 53(3):397-404, 2010 (AHRQ Publication No. 10-R046)* (Intramural).
Health Care Access, Costs, and Insurance
Being foreign-born negatively affects access to care.
Using data on more than 6,000 non-elderly adults in the United States and Canada, researchers found that foreign-born adults in the United States were 48 percent less likely than native-born adults to have seen a health professional in the preceding 12 months. When they looked at the joint effects of nativity and race/ethnicity on access to care, the disparities were even greater. For example, foreign-born Hispanics had 55 percent lower odds of having a regular medical doctor than native-born non-Hispanic whites. LeBrun and Shi, J Health Care Poor Underserved 22(3):1075-1100, 2011 (AHRQ grant T32 HS00029). See also Gresenz, Rogowski, and Escarce, Health Serv Res 44(5):1542-1562, 2009 (AHRQ grant HS10770).
Many U.S.-Mexico border residents "cross over" to obtain health care services.
Researchers conducted a survey among U.S. border residents living in Texas about seeking out health care services in Mexico. More than half of the 1,405 survey respondents said they crossed the border to use one of four types of services in Mexico: visits to doctors, medications, dental visits, and hospital admissions. Factors asso ciated with crossing the border to obtain health care services included no health insurance, dissatisfaction with the quality of care in the United States, and self-reported poor health status. Nearly half of those participating in the survey did not have health insurance. Su, Richardson, Wen, and Pagan, Health Serv Res 46(3):859-876, 2011 (AHRQ grant HS17003).
Enrollment in Medicare Advantage plans reduces disparities in primary care quality in three States.
According to this analysis of 2004 hospital discharge data from AHRQ's Healthcare Cost and Utilization Project, patients enrolled in Medicare Advantage managed care plans in California, Florida, and New York had a lower incidence of preventable hospitalizations across all racial/ethnic groups, compared with those enrolled in fee-for-service Medicare. According to the study's author, better care coordination and use of primary and preventive care may be especially beneficial for minorities, since they often are vulnerable and need such support. Basu, Health Care Manag Sci 15(1):15-28, 2012 (AHRQ Publication No. 12-R014)* (Intramural).
Americans, especially blacks, spend substantial periods of time uninsured.
Researchers used mortality data from the National Center for Health Statistics and data on health and health insurance status on 34,403 individuals participating in AHRQ's Medical Expenditure Panel Survey (MEPS) in 2004 to examine the risk of being uninsured. They found that among those aged 20-24, blacks were uninsured 43 percent of the time, compared with 36 percent of the time for same-age whites. Differences between blacks and whites were particularly large between the ages of 50 and 60, when health begins to decline and Medicare coverage has yet to begin. Kirby and Kaneda, Demography 47(4):1035-1051, 2010 (AHRQ Publication No. 11-R037)* (Intramural).
Some minority patients have difficulty accessing care provided by community health centers.
Researchers studied access to care provided by four community health centers (CHCs) located in States with a higher-than-average percentage of Asian American, Native Hawaiian, and other Pacific Islander patients. They found that while the CHCs served as safety nets for some of the most vulnerable patients, many patients were unable to access or use the CHC care unless enabling services (e.g., language interpretation, health education, and financial or insurance eligibility assistance) were provided. Compared with nonusers, users of enabling services were more likely to be older, female, and uninsured. Weir, Emerson, Tsent, et al., Am J Public Health 100(11):2199-2205, 2010 (AHRQ grant HS13401).
Asian Americans enrolled in traditional fee-for-service Medicare receive fewer needed services than white patients.
Researchers examined the association of race/ethnicity and socioeconomic status with the use of two Medicare-covered cancer screening services (colorectal cancer screening and mammography) and three diabetes-related care services (blood sugar measurement, eye exams, and self-care instructions) among elderly whites and Asian Americans. The study focused on the metropolitan statistical areas (MSAs) with the largest number of elderly Asians in 2000, including Los Angeles, New York City, and Washington, DC. Asians were less likely than whites to receive colorectal cancer screening and mammography, while Asian-white disparities in diabetes care were less consistent and varied according to geographic region. Outside of the nine MSAs studied, Asian-white differences were significant across both cancer screening services and all three diabetes services. Cancer is the leading cause of death among Asians, and diabetes-related conditions rank fifth. Moy, Greenberg, and Borsky, Health Aff 27(2):538-549, 2008 (AHRQ Publication No. 08-R064)* (Intramural).
HIV care sites serving a large proportion of blacks and Hispanics may be difficult to access for all patients.
Researchers surveyed 915 HIV-infected adults receiving care at 14 U.S. HIV clinics and found that, on average, blacks and Hispanics spent more time traveling to the care site than whites (36 and 37 vs. 29 minutes). Further, travel time to the HIV care site lengthened as the proportion of black and Hispanic patients increased at a given site. Finally, waiting times at care sites were longer for Hispanics and blacks than whites (36 and 31 vs. 27 minutes). Korthuis, Saha, Fleishman, et al., J Gen Intern Med 23(12):2046-2052, 2008 (AHRQ Publication No. 09-R032)* (Intramural). See also Ford, Daniel, Earp, et al., Am J Public Health 99(S1):5137-5143, 2009 (AHRQ grant T32 HS00032).
Black and Hispanic Medicare patients often wait longer than white patients for surgery after hip fracture.
According to this study, black and Hispanic Medicare patients with hip fractures had approximately a half-day delay in receiving hip stabilization surgery compared with white patients. Most often, the delay in surgery was due to the need to evaluate and stabilize other medical problems, such as chest pain. Other possible explanations include the higher prevalence in blacks and Hispanics of undiagnosed and uncontrolled medical conditions such as diabetes and hypertension or delayed transportation to the hospital leading to an afternoon admission and surgery deferral until the next day. Nguyen-Oghalai, Kuo, Wu, et al., South Med J 103(5):414-418, 2010. See also Nguyen-Oghalai, Ottenbacher, Kuo, et al., Arch Physical Med Rehab 90:560563, 2009 (AHRQ grant HS11618).
Disparities in outpatient care and expenditures have widenedfor Hispanics but not for blacks.
To explore trends in care disparities, researchers analyzed data on office-based or outpatient visits for two time periods: 1996-1997 and 2004-2005. They found that medical care spending for whites and blacks increased significantly (over $1,500) over those years, but there was a much smaller increase (about $400) in spending for Hispanics. Hispanic-white disparities in outpatient care visits increased between 1996 and 2005, while black-white differences remained relatively constant. Le Cook, McGuire, and Zuvekas, Med Care Res Rev 66(1):23-48, 2009 (AHRQ Publication No. 09-R019)* (Intramural).
Minority children are half as likely as white children to receive specialized therapies.
This study found that 3.8 percent of children aged 18 or younger obtain specialized therapies from the health care system, including physical, occupational, and speech therapy and home health care services. Children most likely to use specialized therapies tend to be male (59.7 percent), white (80.6 percent), and have a chronic condition (38.8 percent). Black children, Hispanic children, and children of other races were much less likely than white children to receive special therapies. These findings suggest that either minority children are underusing therapies or white children are overusing them, according to the researchers. Kuhlthau, Hill, Fluet, et al., Dev Neurorehabil 11(2):115-123, 2008 (AHRQ grant HS13757).
More blacks than whites have trouble affording their prescription medicines.
Researchers recruited elderly black and white patients from 48 primary care practices in Alabama. Patients were asked about their ability to pay for prescriptions, their insurance coverage, coexisting medical conditions, and socioeconomic status. Blacks were twice as likely as whites to not fill a prescription (50 vs. 25 percent) and were far more likely to report inadequate income to meet basic needs (61 vs. 17 percent). Of 399 participating patients, 53 percent had an annual household income of less than $15,000. Cobaugh, Angner, Kiefe, et al., Am J Health Syst Pharm 65:21372143, 2008 (AHRQ grant HS10389).
Immigrants use fewer preventive services than U.S. natives.
Researchers compared use of preventive care services by immigrants and native-born residents and found that U.S. natives had more medical and dental visits, received more flu shots, and were screened more often for high cholesterol levels and cervical, breast, and prostate cancers. Although immigrants' use of preventive services increases the longer they stay in the United States, their use never matches that of U.S. natives. Immigrants are likely to be uninsured when they arrive in the United States, but even after they obtain continuous coverage, they still are less likely than U.S. natives to use preventive care. Pylypchuk and Hudson, Health Econ; E-pub August 2008 (AHRQ Publication No. 09-R025)* (Intramural).
Hispanics enrolled in Medicare managed care plans are less positive than whites about their care experiences.
More than half of Hispanics insured through Medicare were enrolled in managed care programs in 2002. A 2002 survey included 125,369 respondents enrolled in 181 Medicare managed care programs nationally. Responses from white enrollees were compared with responses from Hispanic enrollees; also, responses from Hispanics who completed the survey in English were compared with those who completed the survey in Spanish. English-speaking Hispanics viewed all aspects of their care—except provider communications—worse than whites did. Spanish-speaking respondents reported more negative care experiences with timeliness of care, provider communications, and office staff helpfulness but were more satisfied with getting needed care. Weech-Maldonado, Fongwa, Gutierrez, and Hays, Health Serv Res 43(2):552-568, 2008 (AHRQ grant HS16980).
Researchers examine the effects of various factors on children's health insurance coverage.
Children of different racial and ethnic groups vary substantially with respect to health insurance coverage. These researchers explored how much a given characteristic contributes to coverage differences, using a recently developed statistical technique—decomposition analysis. They found that observable characteristics such as poverty, parent educational level, family structure (for black children), and immigration-related factors (for Hispanic children) account for 70 percent or more of the coverage differences among white, black, and Hispanic children. They conclude that the lower coverage levels among ethnic and racial minorities are due to the fact that uninsurance is concentrated among socioeconomically disadvantaged children who happen to be minorities. Pylypchuk and Selden, J Health Econ 27(4):1109-1128, 2008 (AHRQ Publication No. 08-R068)* (Intramural).
Geographic information system may pinpoint areas where increased primary care is needed.
Using the Multiple Attribute Primary Care Targeting Strategy (MAPCATS), researchers were able to identify geographic regions where increasing access to primary care services for the Hispanic community would have the greatest potential impact on health outcomes. They used MAPCATS to analyze five key attributes of the Hispanic population in Charlotte, NC: socioeconomic status, population density, insurance status, patterns of emergency department use, and use of the primary care safety net. The attributes were combined with input from health providers and community members to create a composite map that showed the community's overall primary care needs. Dulin, Ludden, Tapp, et al., Am Board Family Med 23(1):109-120, 2010 (AHRQ grant HS16023).
Some minority patients voice concerns about using telemedicine to expand access to care.
Telemedicine holds promise as a way to compensate for physician shortages and overcrowding in inner city health facilities. This study found that inner city blacks and Hispanics view the benefits of the technology similarly, but blacks tend to be more wary of telemedicine. Their concerns centered mostly on the inability to check a doctor's qualifications and uncertainty about the telemedicine equipment's ability to protect privacy and confidentiality. George, Hamilton, and Baker, Telemed J E Health 15(6):1 -6, 2009 (HS14022).
Research finds a link between PTSD and elevated blood sugar in low income minorities.
Researchers studied 103 low income minority patients with type 2 diabetes who were being treated at one of four community-based primary care clinics in Harlem. They found that 12 percent of these men and women had full posttraumatic stress disorder (PTSD), and another 12 percent had sub-threshold PTSD. The most common sources of trauma were childhood physical abuse (22 percent) and the death of a child (18 percent). Those who had full PTSD were significantly more likely to have an elevated HBA1C level. Patients with PTSD also were more likely to suffer from depressive symptoms and to be taking a psychiatric medication. Miller, Mancuso, Boutin-Foster, et al., Gen Hosp Psychiatry 33:116-122, 2011 (AHRQ grant T32 HS00066).
Among adolescents, whites are much more likely than blacks or Hispanics to use antidepressants.
According to this analysis of data from AHRQ's Medical Expenditure Panel Survey, white adolescents are more than twice as likely as Hispanic adolescents and almost five times as likely as black adolescents to use antidepressants. The researchers note that much of the Hispanic/white gap may be explained by two-parent families, family income, education, health insurance, and having a usual source of care. On the other hand, the black/white gap may be due in part to the way minorities perceive mental health difficulties and the use of antidepressants by adolescents. Kirby, Hudson, and Miller, Med Care Res Rev 67(3):342-363, 2010 (AHRQ Publication No. 10-R072).* See also Hudson, Miller, and Kirby, Med Care 45(11):1068-1075, 2007 (AHRQ Publication No. 08-R044)* (lntramural).
Less-accultured Latinos use fewer mental health services than others.
An analysis of data on use of mental health services by the three largest Latino groups in the Nation (Mexicans, Cubans, and Puerto Ricans) revealed that those who were less accultured and more medically self-reliant used fewer mental health services than others. Mexicans (4.5 percent) and Cubans (5.7 percent) were less likely than whites (9.3 percent) to use any mental health service, but use by Puerto Ricans (8.3 percent) was not significantly different from that of whites. Lower English language proficiency and less time spent in the United States were associated with the lowest use of mental health services. Berdahl and Torres Stone, Community Ment Health J 45:393-403, 2009 (AHRQ Publication No. 10-R006)* (Intramural).
Blacks and whites spend about the same amount of time in office visits with psychiatrists.
From 2001 to 2003, black patients had office-based visits with psychiatrists that were an average of 4.4 minutes shorter than visits by white patients (28.3 vs. 32.7 minutes). By 2004-2006, the time spent with a psychiatrist was about the same for black and white patients. Between these periods of time, there were longer visits by black patients rather than shorter visits by white patients, suggesting that the change was not mediated by treatment patterns. Olfson, Cherry, and Lewis-Fernandez, Arch Gen Psychiatr 66(2):214-221, 2009 (AHRQ grant HS16097).
Intervention may improve access to depression care for minority youths.
These researchers studied the impact of a quality improvement intervention designed to improve access to evidence-based depression care for minority youths. Results showed a significant reduction in depression symptoms among blacks in the intervention group. Among Latinos, the only improvement was in care satisfaction, while there were no intervention effects for white youths. Ngo, Asarnow, Lange, et al., Psychiatr Serv 60(10):1357-1364, 2009 (AHRQ grant HS09908).
Asian Americans resist using mental health services.
According to this study, Asian Americans may resist using Western mental health services for many reasons, including stigma, fear of institutionalization, and lack of faith in the benefits of psychotherapy. Those who do seek mental health care are among the most severely disturbed. This analysis of New York City data found that schizophrenic disorders were the most frequent diagnoses among Asians, with a rate twice as high for Asians as for other groups. They also stayed in the hospital longer than other patients: 2.59 additional days for Asians, compared with 1.67 additional days for other groups. Shin, Issues Ment Health Nurs 30:112-121, 2009 (AHRQ grant HS00149).
Blacks and Hispanics are less likely than whites to seek treatment for mental health problems.
Researchers used 2001-2004 Medical Expenditure Panel Survey data to explore why minorities seek mental health services less frequently than whites. Just 7 percent of those surveyed reported fair or poor mental health, and whites were more likely than blacks to associate their mental symptoms with their mental health status. According to the authors, this finding suggests that the gap between whites, blacks, and Hispanics using mental health services likely reflects underuse by minorities and not overuse by whites. Zuvekas and Fleishman, Medical Care, 46(9):915-923, 2008 (AHRQ Publication No. 09-R007)* (Intramural).
Racial disparities affect physician-patient communication about mental health problems.
This study involved primary care visits made by 46 white and 62 black nonelderly adults with symptoms of depression who were seen by physicians in urban community-based practices. Communication about depression occurred in only about one-third of the visits (43 percent of white visits and 27 percent of black visits). Black patients were less likely than white patients to talk about their depression (11 vs. 38 statements, respectively). Also, physicians made fewer rapport-building statements during visits with black patients (21 statements) than during visits with white patients (30 statements). Even in visits where communication about depression occurred, physicians considered fewer black (67 percent) than white (93 percent) patients as suffering significant emotional distress. Ghods, Roter, Ford, et al., J Gen Intern Med 23(5):600-606, 2008 (AHRQ grant HS13645).
Certain types of therapy are more effective for minority youth with psychosocial problems.
This review of the evidence found that psychotherapy is moderately effective for many mental health problems experienced by minority youth, although some treatments seem to work better than others. For example, multisystemic therapy is the only therapy shown to reduce criminal offending among black delinquent youths. It is delivered in the young person's home or school by specially trained therapists. Cognitive behavioral therapy and individual psychotherapy are preferable when treating depression in Latino adolescents. Ethnic minority youths seem to respond best to treatments that are highly structured, time-limited, pragmatic, and goal-oriented, note the researchers. Huey and Polo, J Clin Child Adolesc Psychol 37(1):262-301, 2008 (AHRQ grant HS10870).
Underserved blacks and Hispanics with depression often use alternative medicine for their symptoms.
This study involved data on 315 patients with depression from two outpatient primary care clinics in Los Angeles; 66 percent of the patients were Hispanic, and 20 percent were black. Nearly 60 percent of the patients reported using complementary and alternative medicine (CAM) to manage their symptoms sometimes, and 24 percent used it often. Lack of health insurance was one of the strongest predictors of CAM use. These findings suggest that CAM use among underserved minority individuals may serve as a substitute for conventional care when access to care is limited or unavailable, note the researchers. Bazargan, Ani, Hindman, et al., J Altern Complement Med 14(5):537-544, 2008.
Study finds lower flu vaccination rates for black nursing home residents in same facilities.
The average flu vaccination rate among nursing home residents nationwide was 72 percent during the 2005-2006 flu season, but the odds of being vaccinated were 14-16 percent lower for blacks than for whites within the same facility. Also, nursing homes with high proportions of black residents had lower vaccination rates for both black and white residents compared with homes that had a lower proportion of black residents. The researchers note that blacks are consistently more likely than whites to refuse flu vaccinations when offered; they also suggest that low revenue, insufficient staffing, and poor-quality care may contribute to the lower vaccination rates in these facilities. Cai, Feng, Fennell, and Mor, Health Aff 30(10):1939-1946, 2011 (AHrQ grant HS16094).
Culturally appropriate interventions raise flu and pneumonia vaccination rates at inner-city health centers.
Researchers undertook a 4-year trial involving predominantly minority and economically disadvantaged patients older than age 50 using proven, culturally appropriate interventions at four inner-city health centers and compared the results with another center that received no intervention (the control). Over the 4-year trial, annual flu vaccination rates increased from 27 percent to 49 percent at the intervention sites, while the control site continued to have low rates of vaccination (20 percent). Intervention sites also increased use of pneumonia vaccinations, from 48 percent to 81 percent in patients aged 65 and older. Increases in vaccination rates were observed among white and Hispanic patients. Nowalk, Zimmerman, Lin, et al., J Am Geriatr Soc 56(7):1177-1182, 2008 (AHRQ grant HS10864).
Quality of Care/Patient Safety
Efforts to improve quality may not always reduce racial/ethnic disparities.
These authors provide a brief overview of how efforts to reduce racial and ethnic disparities came to focus on quality improvement activities. They highlight five challenges to reducing disparities through quality improvement and describe specific analyses that should be incorporated into such activities. Weinick and Hasnain-Wynia, Health Aff 30(10):1837-1842, 2011 (AHRQ grant to the Harvard Interfaculty Program for Health System Improvement).
Many black mothers are skeptical about the relationship between infant sleep position and SIDS.
Black infants are twice as likely as white infants to die from SIDS, and they are also twice as likely to be placed on their stomachs to sleep, despite American Academy of Pediatrics recommendations that infants sleep on their backs to reduce the risk of sudden infant death syndrome. Researchers conducted 13 focus groups with 73 black mothers of infants, as well as 10 individual interviews, to examine perceptions about SIDS among black parents. They found that the mothers perceived the link between sleep position and SIDS to be implausible, SIDS to be random and unpreventable, and parental vigilance to be the key to SIDS prevention. Moon, Oden, Joyner, and Ajao, J Pediatr 157:92-97, 2010. See also Oden, Joyner, Ajao, and Moon, J Natl Med Assoc 102(10):870-880, 2010, and Joyner, Oden, Ajao, and Moon, J Natl Med Assoc 102(10):881-889 (AHRQ grant HS16892).
Having a strong social network plays a critical role in health status.
Researchers administered a 22-item survey to 1,074 women to examine whether a multidimensional, social support instrument originally developed for older Chinese and Koreans could be used for meaningful comparisons across four ethnic groups of women (black, white, Hispanic, and Chinese). Social support items in the survey were divided among three categories: tangible support, informational support, and financial support. Using the survey results, the researchers derived a valid and reliable eight-item social support instrument that is available in English, Spanish, and Chinese. Wong, Mordstokke, Gregorich, and Perez-Stable, J Cross Cult Gerontol 25:45-58, 2010 (AHRQ grant HS10856).
Certain hospitalized patients are at increased risk for an adverse event.
In this study of Medicare patients hospitalized in 3,648 hospitals, researchers found that blacks had a higher risk than whites of suffering from a health care-associated infection or adverse drug event. In addition, patients of all races treated in hospitals with the highest percentage of black patients had a significantly higher risk of hospital-acquired infection or adverse drug event than patients discharged from hospitals with the lowest percentage of black patients. Metersky, Hunt, Kilman, et al., Med Care 49(5):504-510, 2011 (AHRQ Publication No. 11-R050)* (Intramural).
Black Medicare enrollees have more problems accessing care than white enrollees.
A review of survey results from 101,189 white and 8,791 black Medicare enrollees revealed that blacks have far worse experiences than whites with getting care quickly, getting needed care, office staff helpfulness, and health plan customer services. Blacks also rated their specialist care and health plans more negatively than whites. On the other hand, blacks did report better provider communication than whites and rated their personal doctors and nurses more positively. Fongwa, Cunningham, Weech-Maldonado, et al., J Health Care Poor Underserved 19(4):1136-1147, 2008 (AHRQ grants
HS09204 and HS16980).
Study compares trends in disparities over time.
These researchers used 1996-2005 data from AHRQ's Medical Expenditure Panel Survey (MEPS) to examine trends in disparities and assess the influence of changes in socioeconomic status among racial/ethnic minorities on disparity trends. They found that black-white disparities in having an outpatient visit were roughly constant between 1997 and 2005, while Hispanic-white disparities increased for outpatient visits and for medical expenditures during the same period. Le Cook, McGuire, and Zuvekas, Med Care Res Rev 66(1):23-48, 2009 (AHRQ Publication No. 09-R019)* (Intramural).
Payers and policymakers can incorporate disparity reduction goals into pay-for-performance strategies.
One concern about pay-for-performance strategies is their potential to have a negative impact on racial/ethnic disparities in care. These researchers suggest ways that payers and policymakers can incorporate disparity reduction goals into existing pay-for-performance programs. Such strategies should include performance measures that target disparities, and they should reward performance improvement in addition to achievement. Also, payers and health care organizations should tie pay-for-performance incentives to disparity reduction by stratifying quality of care data according to racial/ethnic groups. Chien and Chin, J Gen Intern Med 24(1):135-136, 2009 (AHRQ grant HS17146).
AHRQ tool helps English- and Spanish-speaking consumers reduce medication errors.
As a group, Hispanics tend to rely on friends and coworkers for health care-related advice before turning to the expertise of medical professionals. AHRQ has published a new guide and medication tracking tool (available in English and Spanish) in conjunction with the National Council on Patient Information and Education to help consumers reduce medication errors. The guide can be personalized, and it includes a detachable, wallet-sized card that can be used by patients to keep track of all their medicines, including vitamins and other supplements. Su medicamento: Informese. Evite riesgos (Your Medicine: Be Smart, Be Safe) (AHRQ Publication No. 11-0049-A, English and 11-0049-B, Spanish)* (Intramural).
Blacks are more likely than members of other racial/ethnic groups to take part in medical decisionmaking.
This survey of 924 diabetes patients being treated at 34 community health centers revealed that black patients are more likely than whites or other minority patients to initiate discussions with their physicians about four of six areas of diabetes care. Researchers asked survey participants about their behaviors related to making medical decisions and assessed their preferences for shared decisionmaking (agenda setting, information sharing, and decisionmaking). There was no association between race and the three preferences. Peek, Tang, Cargill, and Chin, Med Decis Making 31:422-431, 2011 (AHRQ grant HS10479). See also Garcia-Gonzalez, Gonzalez-Lopez, Gamez-Nava, et al., J Clin Rheumatlol 15(3):120-123, 2009 (AHRQ grant HS16093).
Medication adherence improves when patients are treated by providers of the same race.
This study of 131,277 adults with diabetes found that receiving treatment from a doctor of the same race—or one who speaks the same language—as the patient may improve medication adherence rates among blacks and Hispanics who lack proficiency in English. For example, when blacks had black doctors, adherence rates rose to 53.2 percent compared with 49.8 percent for blacks who did not have black doctors. Among Hispanics, adherence rates improved for those whose doctors spoke Spanish (50.6 percent) compared with those who did not (44.8 percent). Traylor, Schmittdiel, Uratsu, et al., J Gen Intern Med 25(11): 1172-1177, 2010 (AHRQ grant HS13902). See also Gerber, Cho, Arozullah, et al., Am J Geriatr Pharmacother 8(2):136-145, 2010 (AHRQ grant HS13004); Rathore, Ketcham, Alexander, et al., J Gen Intern Med 24(11):1183-1191, 2009 (AHRQ grant HS15699); and Kim, Howard, Kaufman, and Holmes, J Natl Med Assoc 100(10):1386-1393, 2008 (AHRQ grant HS13353).
Doctor/patient communication style differs between white and Hispanic HIV patients.
According to this study of HIV patients and physicians in New York City and Portland, OR, Hispanics are much less likely than whites to engage in patient-centered conversations with their providers. Even Hispanics who were fluent in English were less likely than whites to talk with their providers about psychosocial issues. Because discussions about HIV care are often complex and emotionally charged, the researchers suggest that health care providers pay particular attention to psychosocial issues during encounters with all patients. Beach, Saha, Korthuis, et al., J Gen Intern Med25(7):682-687, 2010 (AHRQ contract 290-01-0012).
Report examines the effects of race/ethnicity and insurance status/income on quality of care for children.
The authors of this report describe the joint effects of race and insurance status/income on children's health care quality across a set of 23 quality indicators. Racial and ethnic disparities varied by income level and type of insurance. A key finding is that for the same income level or type of insurance, some racial/ethnic groups had more pronounced differences in quality of care than others. Berdahl, Owens, Dougherty, et al., Acad Pediatr 10(2):95-118, 2010 (AHRQ Publication No. 10-R057)* (Intramural).
Pediatricians show less implicit race bias than others.
Researchers surveyed academic pediatricians about their implicit and explicit racial attitudes and stereotypes and found that pediatricians are less likely to harbor attitudes that favor white Americans than other physicians and individuals. Most of the surveyed pediatricians were white (82 percent), and 93 percent were American-born. The researchers found no link between pediatricians' implicit racial attitudes and stereotypes and quality of pediatric care. Sabin, Rivara, and Greenwald, Med Care 46(7):678-685, 2008 (AHRQ grant HS15760).
Hispanics tend to give more positive ratings of care than whites.
Researchers examined how Hispanic ethnicity and insurance status (Medicaid vs. commercial managed care) affect the use of the 0-10 rating scales in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Previous studies have shown that Hispanics report care that is similar to or less positive than non-Hispanic whites but give more positive ratings of care, and that blacks and Hispanics are more likely than whites to use the extreme responses in a rating scale. In this study, Hispanics were more likely than whites in commercial plans to give the highest rating of "10," but they often gave ratings of 4 or below relative to an omitted category of "5" to "8." The researchers call this "extreme response tendency," which is a tendency to respond systematically to questionnaire items on some basis other than what the items were intended to measure. They suggest pooling responses at the top (9 and 10) and bottom (0 to 6) of a 10-point scale when making racial/ethnic comparisons. Weech-Maldonado, Elliott, Oluwole, et al., Med Care 46(9):963-968, 2008 (AHRQ grant HS11386).
Enhancing cultural competence of clinicians and clinics may reduce care disparities.
Culturally competent clinicians are more likely to understand the language, values, and beliefs of the racial and ethnic groups they serve and to have the attitudes and skills to convey their respect and understanding in the care they provide. This study is the first to link provider cultural competence with the cultural competence of the clinics in which they work. Researchers found that culturally competent clinicians are more likely to work in clinics that have a higher percentage of minority staff, offer cultural diversity training, and provide culturally adapted patient education materials. Enhancing the cultural competence of both clinicians and clinics may be a synergistic approach to reducing health care disparities, according to the researchers. They surveyed 49 providers from 23 clinics in Baltimore, MD and Wilmington, DE. Paez, Allen, Carson, and Cooper, Social Sci Med 66:12041216, 2008 (AHRQ grant HS13645).
Reproductive Health and Birth Outcomes
Perceived lower social standing is linked to unplanned pregnancies.
More than one-third of the 1,000 pregnant women in the San Francisco area who responded to a survey reported that their pregnancies were unplanned. Black women reported the highest rate of unintended pregnancy (62 percent), and white women reported the lowest rate (23 percent). Although just 18 percent of those surveyed were black, they accounted for 33 percent of the unintended pregnancies. The researchers also found that a woman's subjective social standing was associated with unintended pregnancy; the lower the woman's level of self-perceived social standing, the more likely her pregnancy was unplanned. Bryant, Nakagawa, Gregorich, and Kuppermann, J Women's Health 19(6):1195-1200, 2010 (AHRQ grant HS10856).
Researchers find a link between race/ethnicity and risk for gestational diabetes.
According to this analysis of data on nearly 140,000 women who developed gestational diabetes, women who are Asian, Hispanic, or American Indian are more likely than white or black women to develop the condition. Asian women had the highest rate (6.8 percent) of gestational diabetes, followed by American Indian (5.6 percent) and Hispanic (4.9 percent) women; 3.4 percent of white women and 3.2 percent of black women developed gestational diabetes. The rate was even higher when the father was Asian (65 percent), Hispanic (4.6 percent), or American Indian (4.5 percent), compared with white (3.9 percent) or black (3.3 percent) fathers. The researchers suggest that because these racial/ethnic groups originated in Asia, they may share a common genetic risk for developing gestational diabetes. Caughey, Cheng, Stotland, et al., Am J Obstet Gynecol 202(6):616.el-616.e5, 2010 (AHRQ grant HS10856).
Study identifies ways to enhance prenatal care in underresourced settings.
Based on a literature review and key informant interviews, these researchers identified 17 innovative strategies involving health information technology that have been or could be used to improve prenatal care in traditionally underresourced settings that serve black, Hispanic, and Asian American patients, as well as low income children. The strategies could be used to improve the content of prenatal care, increase access to timely prenatal care, and enhance the organization and delivery of prenatal care. Lu, Kotelchuck, Hogan, et al., Med Care Res Rev 67(5 Suppl):198-230, 2010 (AHRQ contract P233200900421P).
One-fifth of mothers do not receive recommended corticosteroids before delivery of premature infants.
Strong evidence shows that administration of antenatal corticosteroids during preterm labor reduces the incidence of respiratory distress syndrome and other complications associated with prematurity. This study of premature births at three New York City hospitals found that 20 percent of eligible mothers did not receive indicated antenatal corticosteroid therapy. The failure to administer recommended steroids was related strongly to how long after admission the delivery took place, as well as lack of prenatal care, longer gestation, advanced cervical exam, and intact membranes at admission. The study included 515 women eligible for corticosteroid therapy; 70 percent of the women were black or Hispanic, and most were insured through Medicaid or a Medicaid HMO. Howell, Stone, Kleinman, et al., Matern Child Health J 14:430-436, 2010 (AHRQ grant HS10859).
Stress and anxiety in pregnant black women contribute to low birthweight babies.
This study of 554 pregnant women (mostly poor, black, and unmarried) seen in the early 1990s at obstetric clinics in Memphis, TN, found that just over 15 percent delivered low birthweight babies. Those who experienced either verbal or physical abuse during their pregnancies delivered babies that were, on average, 3.5 oz lighter than the average-weight babies delivered by mothers who did not suffer abuse. Also, anxious mothers delivered babies that were 2.5 oz lighter than average, and those who experienced neighborhood stress delivered babies that were 2.28 oz lighter. Holland, Kitzman, and Veazie, Women's Health Issues 19(6):390-397, 2009 (AHRQ grant T32 HS00044).
Black women's choice of hospital to give birth may contribute to racial disparities in neonatal deaths.
Black infants in the United States are more than twice as likely to die as white infants during the first month of life (neonatal period). According to this study of records for all live births and deaths of very low birthweight (VLBW) infants born in 45 hospitals in New York City over a 6-year period (19962001), choice of birth hospital had a significant effect on the survival of these fragile newborns. Neonatal mortality rates for infants in this study ranged from 9.6 to 27.2 deaths per 1,000 births. VLBW white infants were more likely to be born in hospitals ranked in the lowest third for neonatal mortality (49 percent), compared with VLBW black infants (29 percent). If black women had delivered in these lower risk hospitals, mortality rates would have been reduced by 6.7 deaths per 1,000 VLBW births, eliminating more than one-third of the black/white disparity in VLBW neonatal mortality rates in New York City. Howell, Hebert, Chatterjee, et al., Pediatrics 121(3):e407-e415, 2008 (AHRQ grant HS10859).
Most pregnant Latinas do not receive recommended screening for intimate partner violence.
Researchers surveyed 210 pregnant Latinas in the Los Angeles, CA, area and found that almost two-thirds of the women had never been asked about being abused. Routine screening of pregnant women for intimate partner violence is recommended by the American College of Obstetrics and Gynecology. Rodriguez, Shoultz, and Richardson, Violence Victims 24(4):520-532, 2009 (AHRQ grant HS11104).
Pregnant Latinas who experience intimate partner violence often suffer from depression.
Researchers surveyed 210 Hispanic women who were pregnant about intimate partner violence, strength (e.g., social support, coping strategies), adverse social behavior (e.g., alcohol and/or tobacco use), depression, and post-traumatic stress disorder (PTSD). More than 40 percent of the women reported intimate partner abuse, including physical, emotional, or sexual abuse. All of the women reported similar levels of mastery (being in control of their lives), but social support was lower for the 92 women who reported abuse, as well as social undermining by their partner (anger, criticism, insults) and stress. Women who were abused were more likely than women who were not to be depressed or have PTSD. Rodriguez, Heilemann, Fielder, et al., Ann Fam Med 6(1):44-52, 2008 (AHRQ grant HS11104).
Gene-environment interactions may explain the black/white disparities in preterm birth and infant mortality.
The authors of this commentary propose that now is the time to translate what has been learned about epigenetic mechanisms in animal studies to the realm of human studies to examine the role of gene-environment interactions (e.g., dietary differences, toxins). Such interactions may contribute to preterm birth and infant mortality, which disproportionately affect black families. Burris and Collins, Ethn Dis 20:296299, 2010 (AHRQ grant T32 HS00063).
Requiring proof of citizenship cut participation in Oregon's Medicaid family planning program.
Proof of citizenship has been a requirement for Medicaid eligibility since implementation of the Federal Deficit Reduction Act in November 2006. Since that time, family planning visits have declined by one-third under the Medicaid-funded Oregon Family Planning Expansion Project. However, the decline in accessing these services was seen in both whites and Hispanics, casting doubt on the need for proof of citizenship to combat Medicaid fraud by noncitizens, according to the researchers. Angus and DeVoe, Health Aff29(4):690-698, 2010 (AHRQ grant HS16181).
Advantage of high survival rates among Iow-weight black infants has diminished.
Using California birthweight data from 1989 to 2004 for black and white infants who weighed 3.3 pounds or less at birth, researchers found that about one-fourth of all babies born with very low birthweights did not survive 30 days after birth. Although black babies had lower mortality rates in 1989 and 1990, this advantage disappeared after 1991. Beginning in 2002, the mortality rate for very low birthweight infants decreased for white babies but rose for black babies. The researchers suggest that the advantage black infants once had may have been eliminated once better access to high-quality prenatal care and therapeutic innovations became more prevalent. Bruckner, Saxton, Anderson, et al., J Pediatr 155(4):482-487, 2009 (AHRQ grant T32 HS00086).
Using pedometers to set activity goals increases physical activity among native elders.
Researchers studied the use of pedometers to increase walking, physical activity, and fitness levels over a 6-week period among American Indian and Alaska Native primary care patients. Participants achieved significant improvements on most outcomes, which included step counts, self-reported physical activity and well-being, and a 6-minute walk test. Sawchuk, Russo, Charles, et al., Am Indian Alsk Native Ment Health Res 18(1):23-41, 2011. See also Sawchuk, Russo, Bogart, et al., Prev Chronic Dis 8(3):1-9, 2011; Sawchuk, Charles, Wen, et al., Prev Med47:89-94, 2008; and Sawchuk, Bogart, Charles, et al, Am Indian Alsk Native Ment Health Res 15(1):1-17, 2008 (AHRQ grant HS108S4).
Study compares treatments to overcome phobia in Asian Americans.
Researchers compared a standard in vivo exposure treatment for phobia, including catastrophic thinking and general fear, in Asian Americans with a culturally adapted similar treatment. They found that Asian Americans with low acculturation benefitted more from the culturally adapted treatment, but the two treatments were equally effective for Asian Americans with high acculturation. Pan, Huey, and Hernandez, Cultur Divers Ethnic Minor Psychol 17(1):11-22, 2011 (AHRQ grant HS10870).
Twenty-seven percent of elementary school children living in Puerto Rico are obese.
According to this 2008 study, elementary school children in Puerto Rico have higher rates of obesity (27 percent) than same-age Hispanic children (25 percent) and non-Hispanic white or black children (19 percent) living in the United States. Another 11 percent of Puerto Rican elementary school children met the criteria for being overweight. Rivera-Soto, Rodriguez-Figueroa, and Calderon, Puerto Rico Health Sci J29(4):357-363, 2010 (AHRQ grant HS14060).
Race is one ofseveral factors in the Nation's epidemic of childhood obesity.
According to this study, 2.7 million U.S. children are severely obese, an increase of more than 300 percent since 1976. Researchers examined data representing 71 million U.S. children and found that black and Mexican American boys aged 12 to 19 are most likely to be severely obese, and children from poor families are also at increased risk for severe obesity. As in adults, severe obesity in children and adolescents can lead to chronic health problems, such as diabetes and cardiovascular disease. Skelton, Cook, Auinger, et al., AcadPediatr 9(5):322-329, 2009 (AHRQ grant HS13901).
Extrapulmonary TB occurs most often in black men.
Although tuberculosis most often affects the lungs, it can also infect other parts of the body such as the lymph nodes and various organs. This extrapulmonary type of TB most often signals a compromised immune system, such as from HIV disease. The researchers compiled data on all 2,142 TB cases reported in the State of Tennessee from 2000 to 2006 and found that more than one-fourth (26.1 percent) were extrapulmonary in nature. The rate of extrapulmonary TB was highest in black men (5.93 per 100,000, compared with black women (3.21), men of other races (1.01), and women of other races (0.58). Fiske, Griffin, Erin, et al., BMC Infect Dis 10(16):1-8, 2010 (AHRQ grant HS13833).
MRSA infections have increased among American Indian/Alaska Native individuals.
Researchers examined outbreaks of methicillin-resistant Staphylococcus aureus (MRSA) infections among American Indians and Alaska Natives (AI/ANs) and found that nationwide hospitalization rates for MRSA infection in AI/ANs increased between 1996 and 2005 (from 4.6 to 50.6 per 100,000). Hospitalization rates were highest for young AI/AN children and nonelderly adults, and skin and soft tissue infections were the most commonly diagnosed. The highest prevalence of MRSA infections were in the Indian Health Service regions of Alaska and the Southwest. Byrd, Holman, Bruce, et al., Clin Infect Dis 49(7):1009-1015, 2009 (AHRQ Publication No. 10-R016)* (Intramural).
Poor blacks have the worst long-term outcomes from work-related back pain.
This review of outcomes among workmen's compensation (WC) claimants in Missouri found that more than 6 years after settlement of WC claims, lower socioeconomic status, black race, and poor early adjustment were associated with poorer long-term adjustment among claimants with low back pain. These individuals were found to have higher levels of pain, pain-related disability, and catastrophic thinking while in pain. Black claimants also had higher rates of occupational disability than other claimants, as evidenced by long-term unemployment and receipt of Social Security disability. Chibnall and Tait, Pain Med 10(8):1378-1388, 2009 (AHRQ grants HS13087 and HS14007). See also Bernstein, Gallagher, Cabral, and Bijur, Pain Med 10(1):106-110, 2009 (AHRQ grant HS13924).
Differences in socioeconomic status in childhood correlate with racial differences in disability in adulthood.
This researcher analyzed 1998-2006 data on community-dwelling blacks and whites, beginning at age 65 and continuing every 2 years. She looked at health conditions, behaviors, and disability at baseline in 1998 and compared adult socioeconomic status (SES) with childhood SES. Compared with white parents, black parents of study participants had fewer years of education, and black fathers were less likely to work in certain occupations, such as professional and sales jobs. Black fathers also were more likely to be absent or deceased when black participants were growing up. As adults, black participants had lower educational levels, income, and wealth compared with whites. Over the course of the study, blacks reported more disabilities than whites, and their disabilities increased over time. Bowen, Soc Sci Med 69:433-441, 2009 (AHRQ grant HS13819).
Perceived racism among black women is linked to socioeconomic position.
This study of 1,249 women, aged 40 to 79, living in Connecticut found that both individual and neighborhood socioeconomic position (SEP) may play a role in understanding how racial discrimination is perceived, measured, and processed. Black women who had higher levels of education reported more racial discrimination than those with less than 12 years of education. Interestingly, income and occupation were not associated with perceived racial discrimination among the women in this study. Dailey, Kasl, Holford, et al., Ethn Health 15 :145-163, 2010 (AHRQ grant HS15686)
Older Mexican American men are more accepting than others of physician-assisted suicide.
In this study, Mexican Americans aged 60 to 89 reported stronger agreement with legalizing physician-assisted suicide (52.7 percent) than non-Hispanic whites (33.7 percent), and Mexican American men were more than twice as likely as Mexican American women to agree with it. High religiosity was not a predictor of opposition to legalizing physician-assisted suicide among Mexican Americans, but among non-Hispanic whites, those who were highly religious were much less likely to support its legalization. Espino, Macias, Wood, et al., J Am Geriatr Soc 58(7):1370-1375, 2010 (AHRQ grant HSl4064).
Minority pediatricians are more likely than white pediatricians to care for minority children.
This study found that minority pediatricians treated an average of 20 percent more minority children than white pediatricians; the percentage of minority patients was highest for Hispanic pediatricians (57.9 percent) and black pediatricians (57.6 percent), compared with 33.4 percent for white pediatricians and 40.6 percent for Asian pediatricians. Minority pediatricians also took care of many more publicly insured or uninsured patients than white pediatricians. Basco, Cull, O'Connor, and Shipman, Pediatrics 125(3):460-467, 2010 (AHRQ grant HS15679). See also Sabin, Nosek, Greenwald, and Rivara, J Health Care Poor Underserved 20:896-913, 2009 (AHRQ grant HS1S676).
Researchers examine patients' general attitudes toward doctors' race and ethnicity.
Using a telephone survey, researchers asked 695 whites and 510 blacks in Hamilton County, OH, how they felt about two dimensions of technical competence and interpersonal skills. They found that black patients were more likely than white patients to believe that same-race doctors would better understand their health problems (7 percent vs. 12 percent), and they expected to be more at ease with same race doctors than white patients (27 percent vs. 20 percent). Blacks also were more likely than whites to feel the same way about physicians born in the United States. Malat, van Ryan, and Purcell, J Natl Med Assoc 101(8):800-807, 2009 (AHRQ grant HS13280).
Health literacy test found validfor both English- and Spanish-speaking individuals.
These researchers developed and validated the Short Assessment of Health Literacy—Spanish and English and in a test with 201 Spanish-speaking and 202 English-speaking individuals, found it to have good reliability and validity. Lee, Stucky, Lee, et al., Health Serv Res 45(4):1105-1120, 2010 (AHRQ grant HS13233).
CAHPS survey instrument developed in collaboration with Choctaw Nation Health Services program.
Working together, representatives from AHRQ's Consumer Assessment of Healthcare Providers and Systems (CAHPS) program and the Choctaw National Health Services program have developed the CAHPS American Indian Survey for use in evaluating Choctaw patient experiences at the tribe's various Indian Health Service (IHS) clinics in Oklahoma. The survey has been field-tested and found to be valid; it will be used as the basis for developing additional survey instruments for the IHS to measure quality of care across various health care programs serving tribes in other parts of the country. Weidmer-Ocampo, Johansson, Dalpoas, et al., J Health Care Poor Underserved 20(3):695-712, 2009 (AHRQ grants HS09204 and HS16980).
Using a list of common surnames can help improve estimates of race/ethnicity in patient data.
According to this study, using a list of relatively common surnames from the 2000 Census can yield more accurate estimates of racial/ethnic disparities in care. The 151,671 surnames listed by at least 100 individuals represent nearly 90 percent of all individuals captured by the census. Using the self-reported racial/ethnic affiliations for each surname, together with geographical information, researchers can calculate a set of likelihoods for someone with a specific surname being white, black, Hispanic, or so on. Elliott, Morrison, Fremont, et al., Health Serv Outcomes Res Methodol 9:69-83, 2009 (AHRQ contract 282-00-0005).
Researchers can safely omit race and ethnicity from cesarean rate risk-adjustment models.
Perinatal outcomes such as infant and maternal death, prematurity, and cesarean delivery are used as a measure of the quality of obstetric care. These less desirable outcomes are known to be higher in the black population than in the white population. The objective of this study was to see if adding race and ethnicity to an otherwise identical model would improve the predictive impact of the model. Researchers tested two risk-adjustment models for primary cesarean rates and found that the two models did not differ substantially in predictive discrimination or in model calibration. They suggest that race and ethnicity can safely be left out of cesarean rate risk-adjustment models. Bailit and Love, Am J Obstet Gynecol 69:e1-e5, 2008 (AHRQ grant HS14352).
Researchers examine risk of workplace injury and how racial/ethnic disparities in risk change over time.
The researcher estimated individual workplace injury and illness risk over time for a group of American workers who participated in a 10-year study (1988-1998) and found that white men had a high risk of injury relative to other groups (white women, black men and women, and Latino men and women). Among women, black women had the highest risk of injury. Berdahl, J Public Health 98(12):2258-2263, 2008 (AHRQ Publication No. 09-R020)* (Intramural).
Study results in culturally appropriate survey instruments for use with Hmong Americans.
Because of its history of refugee status, low proportion of English speakers, and cultural beliefs, the Asian Hmong population in central California has low involvement with health care institutions. The researchers worked with Hmong community leaders to develop and focus-group test a linguistically and culturally sensitive survey that can be used to assess knowledge about hypertension care in this population. Wong, Mouanoutoua, and Chen, J Cult Divers 15(1):30-36, 2008 (AHRQ grant HS10276).
National Healthcare Quality and Disparities Reports
Each year since 2001, AHRQ has published two national reports that present detailed information, including charts and updated trend information, on the quality of health care services and disparities (by race and income) in health care in the United States. Copies of the most recent reports are available from AHRQ. National Healthcare Disparities Report, 2011 (AHRQ Publication No. 120006).* National Healthcare Quality Report, 2011 (AHRQ Publication No. 120005).*
For More Information
AHRQ's State Snapshots, an interactive Web-based tool, show how each State is doing on specific health care quality measures, including trending information on whether States have shown improved or worsened care for racial/ethnic minorities and other populations. AHRQ's 2011 State Snapshots are available at http://statesnapshots.ahrq.gov.
AHRQ is partnering with Hispanic-serving organizations to promote the Agency's Spanish-language resources and to encourage consumers to become more active partners in their health care. The Agency now offers more than 30 publications in Spanish that compare treatments for heart and vascular system conditions, diabetes, cancer, bone and joint-related conditions, pregnancy, digestive system ailments, depression, and other conditions. These and their English-language companion guides were produced by AHRQ's Effective Health Care Program, which conducts patient-centered outcomes research and makes research results available to consumers, clinicians, policymakers, and others. To learn more about these guides and other resources, visit the Agency's Web site at http://www.ahrg.gov/consumer/ espanoix.htm.
Other Minority Health Intitiatives
To find out more about other initiatives related to minority health, including the Agency's minority health research agenda, visit http://www.ahrg.gov/research/minorix.htm.
Copies of items in this brief that are marked with an asterisk (*) are available from the AHRQ Publications Clearinghouse. To order a copy, call the clearinghouse toll-free at 1-800-3589295 or send an e-mail to AHRQpubs at ahrq.gov. Please use the AHRQ publication number when ordering.
For additional information about AHRQ's activities, funding for research, or other topics, please visit the AHRQ Web site at www.ahrq.gov.
For questions and comments regarding AHRQ's priority populations research program, you may contact us at Prioritypops at ahrq.hhs.govUS Minorities have poor health – how much is due to little sun – Feb 2013
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