Unequal treatment: report of the institute of medicine on racial and ethnic disparities in healthcare

A very large national study with patients from the National Registry of Myocardial Infarction 2, comprising 275,000 patients, and prospective controlled studies revealed clear differences in the likelihood of receipt of procedures during nearly every phase of diagnosis and treatment of coronary artery disease, with minority patients usually coming up short.

“the very large national study with patients from the National Registry of Myocardial Infarction 2, comprising 275,000 patients [5], and the prospective controlled studies [6] revealed clear differences in the likelihood of receipt of procedures during nearly every phase of diagnosis and treatment of coronary artery disease, with minority patients usually coming up short.”

• cites [5] Taylor, 1997, Can characteristics of a health care system mitigate ethnic bias in access to cardiovascular procedures? Experience from the military health services system, J Am Coll Cardiol sourceDisputed

  Split into 2 atoms — 0 confirmed, 0 partially supported, 2 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Checked by a reasoning model — may be wrong.

  Experimental — accuracy not yet measured
• cites [6] Peterson, 1997, Racial variation in the use of coronary-revascularization procedures, N Engl J Med sourcePartly supported

  Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured

These differences were not found among white patients similarly deemed appropriate for invasive treatment.

“These differences were not found among white patients similarly deemed appropriate for invasive treatment.”

• cites [9] Hemingway, 2001, Underuse of coronary revascularization procedures in patients considered appropriate candidates for revascularization, N Engl J Med sourceCould not verify

  The Results identify nonwhite race as a predictor of receiving medical treatment rather than CABG among appropriate candidates. The paper does not report a corresponding analysis showing that the unspecified 'differences' were absent among white patients (searched for white-patient and race-specific comparisons). (LLM, conf=0.75)

  Experimental — accuracy not yet measured

In a prospective study of 2552 patients seen in London hospitals who were deemed appropriate for cardiovascular procedures according to standardized criteria, nonwhite patients were more likely to receive only medical treatment, rather than CABG, after controlling for demographic and clinical variables.

“in a prospective study of 2552 patients seen in London hospitals who were deemed appropriate for cardiovascular procedures according to standardized criteria, Hemingway and coworkers [9] found that nonwhite patients were more likely to receive only medical treatment, rather than CABG, after controlling for demographic and clinical variables.”

• cites [9] Hemingway, 2001, Underuse of coronary revascularization procedures in patients considered appropriate candidates for revascularization, N Engl J Med sourcePartly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured

The quality of care received by racial and ethnic minorities in the United States is generally lower than that provided to the majority population.

“the quality of care received by racial and ethnic minorities in this country is generally lower than that provided to the majority population.”

White patients have been found to use some clinical services at higher rates than minorities, even when not necessarily indicated.

“White patients have been found to use some clinical services at higher rates than minorities, even when not necessarily indicated.”

Racial and ethnic disparities in healthcare were found across a wide range of disease areas and clinical services, even after correcting for clinical factors such as comorbidities, stage of disease, and age.

“Disparities were found across a wide range of disease areas and clinical services, even after correcting for clinical factors, such as comorbidities, stage of disease, and age.”

Evidence for real and significant disparities extends from preventive services to pain relief at the end of life.

“The committee found that the evidence for real and significant disparities extends all the way from preventive services on one end of the spectrum to pain relief at the end of life on the other.”

Racial and ethnic disparities in health care exist.

“Racial and ethnic disparities in health care exist”

Studies that did not demonstrate disparities were conspicuous by their rarity.

“studies that did not demonstrate disparities were conspicuous by their rarity.”

In almost all articles, studies using rigorous measures of potential confounding variables find that disparities diminish once these variables are included in multivariate analysis.

“in almost all articles, studies that use rigorous measures of potential confounding variables find that disparities diminish once these variables are included in the multivariate analysis.”

Disparities are found even when clinical factors, such as stage of disease presentation, comorbidities, age, and severity of disease, are taken into account.

“Disparities are found even when clinical factors, such as stage of disease presentation, comorbidities, age, and severity of disease are taken into account.”

Racial and ethnic disparities in healthcare were found in virtually all clinical settings.

“They were found in virtually all clinical settings.”

Latino patients with long bone fractures cared for in Los Angeles emergency rooms received pain medication only half as often as non-Latino patients.

“One study reported that Latino patients with long bone fractures, cared for in emergency rooms in Los Angeles, received pain medication only half as often as non-Latino patients.”

Disparities are found across a range of clinical settings, including public and private hospitals, teaching and nonteaching hospitals.

“They are found across a range of clinical settings, including public and private hospitals, teaching and nonteaching hospitals.”

Black patients were less likely to be catheterized when presenting to an emergency room with chest pain.

“were less likely to be catheterized when presenting to an emergency room with chest pain [3].”

• cites [3] Bell, 2001, Equity in the diagnosis of chest pain, Am J Health Behav sourceNot checked — no full text of the source

There is no evidence that any significant proportion of healthcare professionals in the United States harbors overtly prejudicial attitudes.

“The study explicitly says that there is no evidence that any significant proportion of healthcare professionals in the United States harbors overtly prejudicial attitudes.”

Some of the strongest and most consistent evidence for racial and ethnic disparities in care is found in studies of cardiovascular care.

“some of the strongest and most consistent evidence for the existence of racial and ethnic disparities in care is found in studies of cardiovascular care.”

In a study of more than 13,000 New Jersey residents, the likelihood of receiving catheterization within 90 days of an acute myocardial infarction was significantly greater if the patient was white.

“In a study of more than 13,000 New Jersey residents, the likelihood of receiving catheterization within 90 days of an acute myocardial infarction was significantly greater if the patient was white [4].”

• cites [4] Gregory, 1999, Impact of availability of hospital-based invasive cardiac services on racial differences in the use of these services, Am Heart J sourceNot checked — no full text of the source

One analysis of more than 86,000 Medicare patients found that whites were nearly four times more likely than African Americans to receive coronary artery bypass grafting after adjusting for age- and gender-related differences in rates of myocardial infarction.

“One analysis of more than 86,000 Medicare patients found that whites were nearly four times more likely than African Americans to receive coronary artery bypass grafting (CABG) after adjusting for age-and gender-related differences in rates of myocardial infarction.”

African Americans undergo bilateral orchiectomy and amputation at rates 2.4 and 3.6 times greater than their white Medicare peers.

“bilateral orchiectomy and amputation, which African Americans undergo at rates 2.4 and 3.6 times greater than their white Medicare peers.”

Disparities in the care of cardiovascular conditions exist in other developed countries, such as the United Kingdom.

“disparities in the care of cardio-S1378 SURGICAL OUTCOMES IN AFRICAN AMERICANS vascular conditions exist in other developed countries, such as the United Kingdom.”

Greater racial differences in CABG rates were found in the Southeast, particularly in nonmetropolitan areas.

“the authors found greater racial differences in CABG rates in the Southeast, particularly in nonmetropolitan areas.”

Studies indicating equal quality were reporting on VA and military populations.

“Some that indicated equal quality were reporting on VA and military populations.”

A small number of studies suggest that racial and ethnic minority patients are more likely than white patients to refuse treatment.

“A small number of studies suggest that racial and ethnic minority patients are more likely than white patients to refuse treatment.”

Most studies find that significant disparities remain after including confounding variables.

“Most, however, find that significant disparities remain.”

The evidence base for the influence of bias, stereotyping, and clinical uncertainty on disparities is, in large part, indirect.

“the evidence base is, in large part, indirect”

Uncertainty is a plausible contributing factor to disparities, particularly when providers treat patients that are dissimilar in cultural or linguistic background.

“Uncertainty is a plausible contributing factor, particularly when providers treat patients that are dissimilar in cultural or linguistic background.”

Physician recommendation appears to be the major factor in determining whether patients receive invasive cardiac procedures.

“physician recommendation appears to be the major factor in determining whether patients receive invasive cardiac procedures.”

Many sources (health systems, healthcare providers, patients, and utilization managers) contribute to racial and ethnic disparities in health care.

“Many sources (health systems, healthcare providers, patients, and utilization managers) contribute to racial and ethnic disparities in health care.”

Racial and ethnic disparities in cardiovascular care are robust and consistent across a range of studies conducted in different geographic regions with diverse patient populations seen in a range of clinical settings.

“racial and ethnic disparities in cardiovascular care are robust and consistent across a range of studies conducted in different geographic regions with diverse patient populations seen in a range of clinical settings.”

Bias and stereotypical behavior may play a role among the multiple complex factors that influence clinicians' decisions.

“among the multiple complex factors that influence their decisions, bias and stereotypical behavior may play a role.”

Clinical uncertainty, stereotypical behavior, and bias-both conscious and unconscious-may be among the multiple factors that result in disparities.

“clinical uncertainty, stereotypical behavior and bias-both conscious and unconsciousmay be among the multiple factors that result in disparities”

Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in health care.

“Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in health care.”

Contributions to disparities are made by the current complex, economic-driven healthcare environment.

“contributions to disparities are made by the current complex, economic-driven healthcare environment”

No one study reviewed by the committee simultaneously controlled for all variables likely to confound the relationship between race and the receipt of care.

“No one study reviewed by the committee simultaneously controlled for all of the variables likely to confound the relationship between race and the receipt of care.”

Differences in cardiovascular treatment are not due to factors such as racial differences in severity of coronary disease.

“these studies have been able to demonstrate that differences in treatment are not due to factors such as racial differences in the severity of coronary disease.”

Racial differences in clinical presentation or disease severity do not fully explain differences in receipt of services.

“Racial differences in clinical presentation or disease severity does not fully explain differences in receipt of services.”

Disparities appear to arise from a complex interaction of historic, environmental, and behavioral influences.

“disparities appear to arise from a complex interaction of historic, environmental, and behavioral influences.”

Stereotyping can exert powerful effects on thinking and actions at an implicit, unconscious level, even among well-meaning, well-educated persons who are not overtly biased.

“stereotyping can exert powerful effects on thinking and actions at an implicit, unconscious level, even among well-meaning, welleducated persons who are not overtly biased.”