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.
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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).
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