Minority Health: Recent Findings
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.
Source: 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.
Source: 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.
Source: 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.
Source: 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.
Source: 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.
Source: 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.
Source: 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.
Source: 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.
Source: 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 Rheumatol 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).
Source: 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.
Source: Beach, Saha, Korthuis, et al., J Gen Intern Med 25(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.
Source: 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.
Source: 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.
Source: 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.
Source: Paez, Allen, Carson, and Cooper, Social Sci Med 66:1204-1216, 2008 (AHRQ grant HS13645).
- 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.
Source: 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.
Source: 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.
Source: 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.
Source: 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.
Source: 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 (1996-2001), 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.
Source: 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.
Source: 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.
Source: 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.
Source: Burris and Collins, Ethn Dis 20:296-299, 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.
Source: Angus and DeVoe, Health Aff 29(4):690-698, 2010 (AHRQ grant HS16181).
- Advantage of high survival rates among low-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.
Source: Bruckner, Saxton, Anderson, et al., J Pediatr 155(4):482-487, 2009 (AHRQ grant T32 HS00086).