Minority Health: Recent Findings

Program Brief

The mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, effectiveness, and efficiency of health care for all Americans. Toward this aim, AHRQ supports research and other activities designed to improve quality, enhance access to care, and address disparities in health care for racial and ethnic minorities.

This program brief summarizes recent findings from published articles and other reports sponsored by AHRQ and relevant to minority health. 

Contents

Introduction
Improving Health Care for Minority Populations
Cancer
Cardiovascular Disease
Care for the Elderly/Long-Term Care
Chronic Illness
Emergency Care/Hospitalization
Health Care Access, Costs, and Insurance
Mental/Behavioral Health
Pregnancy, Childbirth, and Birth Outcomes
Preventive Services
Quality of Care/Patient Safety
Reducing Disparities
Additional Studies
National Healthcare Quality and Disparities Reports
For More Information 

Introduction

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.

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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 http://www.ahrq.gov/populations/.

This program brief summarizes findings from AHRQ-supported research on minority health reported in the literature and/or published by AHRQ from 2005 through mid-2009. Items marked with an asterisk (*) are available from AHRQ. Select for more information.

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Cancer

• 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.

  Source: 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.

  Source: Du, Fang, and Meyer, Am J Clin Oncol 31(2):125-132, 2008 (AHRQ grant HS16743).

• Minority women are less likely than white women to receive adjuvant therapies following breast cancer surgery.

  Women with breast cancer do not consistently receive adjuvant treatments—such as radiotherapy following lumpectomy and chemotherapy for estrogen receptor-negative tumors—that have been shown to increase survival. In some cases surgeons do not recommend adjuvant therapy because they perceive the risks to outweigh the benefits or because of patient age or physical condition. However, a survey of surgeons at six New York hospitals treating 119 women who did not receive guideline-recommended adjuvant therapy found that minority women were more likely than white women (73 vs. 54 percent) not to receive adjuvant treatment, as were women who were uninsured or had Medicaid coverage compared with those who had Medicare or private insurance (54 vs. 19 percent, respectively).

  Source: Bickell, LePar, Want, and Leventhal, J Clin Oncol 25(18):2516-2521, 2007. See also Bickell, Wang, Oluwole, et al., J Clin Oncol 24(9):1357-1362 (AHRQ grant HS10859).

• 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.

  Source: Bickell, Shastri, Fei, et al., J Natl Cancer Inst 100(23):1717-1723, 2008 (AHRQ grant HS10859).

• Study finds racial disparities in receipt of breast-conserving therapy among women with early-stage breast cancer.

  According to this study of women in Hawaii, Japanese and Filipino women are much less likely than white women to undergo breast-conserving therapy for early-stage breast cancer. The study also found that Filipino and Hawaiian women were more likely than other women to be diagnosed with more advanced breast cancer, while Japanese women were diagnosed earlier. Researchers linked data from the Hawaii Tumor Registry to census and health care claims data and then retrospectively analyzed breast cancer management of 2,030 women (935 Japanese, 144 Chinese, 235 Filipino, 293 Hawaiian, and 423 white women) who were diagnosed with early breast cancer in Hawaii from 1995 to 2001. The researchers note that ethnic differences (e.g., small breast size) and cultural preferences may explain some of the observed differences.

  Source: Gelber, McCarthy, Davis, and Seto, Ann Surg Oncol 13(7):977-984, 2006 (AHRQ grant HS11627).

• Oncologists appear to communicate differently with breast cancer patients, depending on the women's race, age, and other factors.

  Researchers audiotaped initial consultations between 58 oncologists at 14 practices with 405 women newly diagnosed with breast cancer and conducted interviews with patients and physicians immediately before and after the visits. They found that oncologists spent more time engaged in building relationships with white patients than with members of other racial/ethnic groups. The women who asked more questions were younger, white, had more education, and had a higher income. Physicians tended to ask these women more questions than they did other women. Racial differences occurred in almost every communication category examined, potentially leading to disparities in breast cancer outcomes.

  Source: Siminoff, Graham, and Gordon, Patient Educ Counsel 62:355-360, 2006 (AHRQ grant HS08516). See also Carter, Zapka, O'Neill, et al., Palliat Support Care 4:257-271, 2006 (AHRQ grant HS10871).

• 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.

  Source: Du, Sun, Milam, et al., Int J Gynecol Cancer 18(4):660-669, 2008 (AHRQ grant HS16743).

• 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.

  Source: Street and Gordon, Psychooncology 17:244-251, 2008 (AHRQ grant HS10876).

• Patients' race/ethnicity influences discussion of cancer screening with providers.

  Researchers analyzed responses from patient and physician surveys involving 5,978 patients aged 50 to 80 who were treated by 191 primary care physicians in Southern California. They found that patients with less than a high school education were far less likely than college graduates to have discussed screening for colon, breast, or prostate cancer during medical visits with the same physicians. Asians were much less likely than whites to discuss fecal occult blood testing for colon cancer or prostate-specific antigen testing for prostate cancer. On the other hand, black women were more likely than white women to discuss mammography to detect breast cancer.

  Source: Bao, Fox, and Escarce, Health Serv Res 42(3):950-970, 2007 (AHRQ grant HS10770).

• Elderly cancer patients in minority communities are less likely than those in white communities to use hospice care.

  Researchers used Medicare data on individuals dying from breast, colorectal, lung, or prostate cancer to examine whether the racial composition of the census tract where the individual resided was associated with hospice use. They found that nearly half (47 percent) of individuals who lived in areas with fewer black and Hispanic residents used hospice compared with only about one-third (35 percent) of those who lived in areas with a higher percentage of black and Hispanic residents. These differences in hospice use may contribute to disparities in suffering at the end of life and caregiver burden in minority communities.

  Source: Haas, Earle, Orav, et al., J Gen Intern Med 22:396-399, 2007 (AHRQ grant HS10856).

• Poor, minority, and uninsured individuals have reduced access to screening and surgery for colorectal cancer.

  Colorectal cancer is curable if detected early through colonoscopy or other screening methods, yet it is the second leading cause of U.S. cancer-related deaths. Three studies supported by AHRQ examined trends in colorectal cancer screening and access to surgery and found that low-income/poor individuals, the uninsured, and minorities are screened less frequently than others for colorectal cancer, and they are more likely to need emergency surgery for colorectal cancer-related problems such as bowel perforation, peritonitis, or bowel obstruction. Also, patients who were black, Hispanic, Asian, or less affluent and those who had more advanced colorectal cancer were more likely than white, more affluent, and less severely ill patients to have surgery for the condition at hospitals with above average mortality rates. The researchers conclude that there continue to be barriers to high-quality surgical care for minority individuals with colorectal cancer, independent of other patient characteristics.

  Source: Phillips, Liang, Ladabaum, et al., Medical Care 45(2):160-167, 2007 (AHRQ grants HS10771 and 10856); Diggs, Xu, Diaz, et al., Am J Manag Care 13(3):157-174, 2007 (AHRQ grant T32 HS00059); Zhang, Ayanian, and Zaslavsky, J Qual Health Care 19(1):11-20, 2007 (AHRQ grant HS09869). See also Guerra, Dominguez, and Shea, J Health Commun 10:651-663, 2005 (AHRQ grant HS10299).

• Study examines effects of perceived racial discrimination in adherence to screening mammography guidelines.

  Researchers examined receipt of index mammograms at one of five urban hospitals in Connecticut between 1996 and 1998 among 484 black women and 745 white women to identify any links between perceived racial discrimination and black women's adherence to screening mammography guidelines. About 42 percent of black women and 10 percent of white women reported discrimination at some point in their lives, but this perceived discrimination was not associated with nonadherence to age-specific mammography screening guidelines, even after adjusting for other factors. The researchers caution that black women in the study may have underreported discrimination due to the sensitive nature of the topic and their discomfort in talking about it with white phone interviewers. If this is the case, these findings may underestimate its prevalence and effects on regular mammography screening.

  Source: Dailey, Kasl, Holford, and Jones, Am J Epidemiol 165:1287-1295, 2007 (AHRQ grant HS15686). See also Jones, Reams, Calvocoressi, et al., Am J Public Health 97(3):531-538, 2007 (AHRQ grant HS11603); Rauscher, Hawley, and Earp, Prev Med 40:822-830, 2005 (AHRQ grant T32 HS00007).

• Socioeconomic barriers exist to timely diagnosis and treatment of prostate cancer in black men.

  Researchers identified 207 black men and 348 white men recently diagnosed with prostate cancer from the North Carolina Cancer Registry. They found that black men were younger and had less education, job status, and income than white men. Although black men and white men had to travel similar distances for health care, black men still had less access to care. They also had poorer health insurance coverage and less continuity of care than white men, used more public clinics and emergency wards, expressed less trust in their physicians, and were more likely to skip physician visits that they felt they needed. The researchers conclude that barriers to early diagnosis and appropriate care for prostate cancer among black men are related more to socioeconomic position than to lack of education or cultural misunderstanding.

  Source: Talcott, Spain, Clark, et al., Cancer 109(8):1599-1606, 2007 (AHRQ grant HS10861).

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Cardiovascular Disease

• 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.

  Source: Tuhrim, Cooperman, Rojas, et al., J Stroke Cerebrovasc Dis 17(4):226-234 (AHRQ grant HS10859).

• Study finds that several factors underlie racial disparities in hospital care for congestive heart failure.

  Researchers analyzed data on 373,158 patients discharged with heart failure from U.S. hospitals during the period 1995-1997 and found that blacks were nearly twice as likely as whites—and Hispanics were 30 percent more likely than whites—to be admitted to the hospital through the emergency department. Blacks and Hispanics were less likely than whites to have other coexisting medical conditions, and they also were more likely to be admitted to teaching hospitals. Although teaching hospitals usually have better facilities and capabilities than nonteaching hospitals, blacks and Hispanics were much less likely than whites to receive invasive cardiovascular services such as cardiac catheterization, angioplasty, or bypass surgery. Black and Hispanic patients also stayed in the hospital longer and had higher total charges, compared with whites.

  Source: Shen, Washington, Chung, and Bell, Ethn Dis 17:206-213, 2007 (AHRQ grant HS13056).

• Blacks are more likely than whites and Hispanics to die following cardiovascular procedures.

  This study found that irrespective of hospital volume/experience with cardiovascular procedures, blacks are much more likely to die than whites or Hispanics following either of four procedures: cardiac bypass surgery, angioplasty, abdominal aortic aneurysm repair, and carotid artery surgery. These findings suggest that hospital characteristics other than the number of procedures performed—such as financial resources, provider staffing, and availability of ancillary services— may be different in hospitals providing care to large numbers of black patients. Researchers examined data from a national sample on more than 700,000 hospitalizations for the four procedures from 1998 to 2001.

  Source: Trivedi, Sequist, and Ayanian, J Am Col Cardiol 47(2):417-424, 2006 (AHRQ grant T32 HS00020).

• Black patients have worse outcomes that white patients following heart attack or unstable angina.

  Researchers compared symptoms, function, and quality of life of 1,159 patients with acute coronary syndrome who were treated in 2000 and 2001 at two Kansas City hospitals. They found that mortality rates were similar among the 196 black and 963 white patients, after adjustments were made for differences in sociodemographic and clinical characteristics. However, 1 year after treatment, more blacks than whites suffered from angina (43.4 vs. 27.1 percent, respectively), had worse quality of life, and had poorer physical function. Researchers suggest that differences in outpatient treatment, compliance with medications, and biologic mechanisms are responsible for the disparities in outcomes.

  Source: Spertus, Safley, Garg, et al., J Am Coll Cardiol 46(10):1838-1844, 2005 (AHRQ grant HS11282).

• Although U.S. cardiovascular mortality rates are declining, they are rising among American Indians.

  Cardiovascular disease (CVD) is the leading cause of death in American Indians older than age 45, compared with age 65 for the general U.S. population. For this study, researchers examined the development of major CVD risk factors (smoking, hypertension, diabetes, high cholesterol) among 4,549 rural American Indians aged 45 to 74 during the period 1989 (baseline) and 1991 (8 years later). During the study period, participants had a decreased prevalence of smoking and no changes in HDL cholesterol, but they had substantial increases in the prevalence of hypertension and diabetes. Over the 8-year period, the prevalence of hypertension increased from 42.2 percent to 61.3 percent among men and 36.4 percent to 60.3 percent among women. The prevalence of diabetes increased from 41.4 to 47.4 percent among men and 48.4 to 55.8 percent among women.

  Source: Rhoades, Welty, Wang, et al., J Am Geriatr Soc 55:87-94, 2007. See also Rhoades, Circulation 111:1250-1256, 2005 (AHRQ grant HS10854).

• Management of chest pain in patients with hypertension varies by race/ethnicity.

  Researchers analyzed the care of 72,508 people with hypertension who received care from about 50 primary care practices in the Southeastern United States and found that 11 percent of the patients also had chest pain syndrome (general chest pain, angina, and pre-heart attack symptoms). More men than women were diagnosed with angina (18 vs. 4 percent) and intermediate coronary syndrome (21 vs. 20 percent), while more women than men were diagnosed with vague chest pain only (86 vs. 61 percent). Blacks received more chest pain diagnoses than whites, but women and blacks received fewer cardiovascular medications than men and whites.

  Source: Hendrix, Mayhan, Lackland, and Egan, Am J Hypertens 18(8):1026-1032, 2005 (AHRQ grant HS10871).

• Outcomes differ for blacks, whites, and Asian Americans following stroke rehabilitation.

  Researchers analyzed data on 1,002 stroke patients admitted to an inpatient rehabilitation facility between 1995 and 2001 and found differences in outcomes by race. Blacks who suffered a stroke did not improve their functioning by the end of inpatient rehab to the degree that whites did, despite receiving similarly intense rehab services. In contrast, Asian Americans recovered about as much function as whites by the time they left inpatient rehab. By 3 months postdischarge, blacks had caught up to whites and no longer had poorer functioning, while Asian Americans showed less improvement than whites at 3 months.

  Source: Bhandari, Kushel, Price, and Schillinger, Arch Phys Med Rehabil 86:2081-2086, 2005 (AHRQ grant HS11415).