Aug 1, 2020

Disparities in healthcare: We’ve all got work to do

The idea of disparities existing in healthcare is not new; it’s something the industry has grappled with for decades. Data produced over several years shows an inherent bias in healthcare. However, because of recent events—examples of inequities uncovered during the COVID-19 pandemic; the glaring, unfortunate examples of systemic racism in our country; and the ongoing the Black Lives Matter movement—the conversation around disparities has received (much needed) renewed attention.

The motivation for change to end healthcare disparities is, and should be, at an all-time high. Now is the critical time for all of us in healthcare to have honest conversations with ourselves and each other about how we can be better and DO better. We all need to educate or re-educate ourselves and our staffs about how to recognize practices that can contribute to health disparities, and to identify ways we can measure how our efforts may be contributing to them.

Consider these statistics and associated studies—many of which are not new—which paint a long-term, disturbing picture of the racial disparities that have existed in healthcare for many years:

  • 1993, 2000: Hispanics and blacks were under-treated for pain from fractures of long bones. (Todd et al; JAMA 269: 1537-9; Ann Emerg Med 35: 11-6)
  • 1996: Postoperative pain was inadequately managed if patient was not white. (Ng B et al; Pain 66: 9-12)
  • 2000: Blacks and Hispanics with severe pain are less able than whites to obtain common meds. (Morrison RS et al; NEJM 342: 1023-6)
  • 1993: Blacks are less likely than whites to undergo thorough diagnostic evaluation for symptoms suggestive of life-threatening CAD*
  • Blacks are 13-40% less likely to receive angioplasty.*
  • Blacks are 32-70% less likely to receive bypass surgery.*
  • Pregnant Black women receive less adequate prenatal care.
  • Black children are significantly less likely to receive prescription drugs, and 25 times more likely to die from asthma.
  • Blacks are more likely to receive diagnoses of substance abuse, while rates are actually similar to whites, and are more likely to be admitted to mental health facilities involuntarily or to be restrained or placed in seclusion.
  • Suicide rates among Black children (ages 10-19) are 116-165% higher.
  • 1999: Blacks with chronic renal failure are less likely than whites to be referred for and undergo transplantation.

What can we do next?

The first and most important thing we can do is to acknowledge that this is a very real problem, and to go back to why we chose this profession – we took an oath to help people, regardless of their race, social status, or economic status. Humanism is at the fabric of the medical profession. As healthcare providers, we have an obligation to treat ALL people equally. And of course, equity is one of the six aims of healthcare quality (the others being safety, effectiveness, being patient-centered, timeliness, and efficiency).

The second thing we can do is to educate ourselves that there are inherent differences in how we treating patients, and to ensure that we have systems in place to actually measure the results of those differences, so we can correct it. Without the data, we’ll never be able to quantify the problem. To get an accurate look at healthcare quality, it’s important to study race, ethnicity, and gender to identify gaps and trends.

There is great distrust of the healthcare system right now. One more thing we can do to help improve that trust is to adhere to the “LEARN” model** when working with our patients:

  • LISTEN actively with respect.
  • ELICIT the health beliefs of the patient.
  • ASSESS priorities, values, and supports.
  • RECOMMEND a plan of action with adequate explanation and understanding.
  • NEGOTIATE by involving the patient in next steps and decisions.

The LEARN model is a communication framework designed to help healthcare providers overcome communication and cultural barriers to successful patient education.

This is just the starting point for very important discussions we hope to have together going forward. And as always, thank you for everything you continue to do to keep Rhode Islanders safe and healthy.

*Peterson ED et al; NEJM 336, 480-6; Weitzman S et al; Am J Cardiology 79: 722-6

**Berlin EA. & Fowkes WC. (1983). A teaching framework for cross cultural health care: Application in family practice. West J. Med. 12(139), 93-98.)