July 5, 2005 STANFORD, Calif. - A new study from the Stanford University School of Medicine has found that once U.S. patients visit a doctor for outpatient care, their race and ethnicity make little difference in the quality of care they receive. But the study also found that health-care providers have a lot of room for improvement when it comes to caring for all of their patients. In fact, it suggests there were only limited improvements in outpatient care during the 10-year study period.
"We observed similar, though less-than-optimal, outpatient care across all racial and ethnic groups using visit-based, physician-provided national data," said Jun Ma, MD, PhD, research associate at the Stanford Prevention Research Center and lead author of the study that appears in the June 27 issue of the Archives of Internal Medicine. The results should be interpreted carefully, Ma said, as the data set represents only a small snapshot of the nation's health-care landscape-namely, those who obtained care in the first place.
Ma and her collaborator Randall Stafford MD, PhD, associate professor of medicine, designed the study to fill in some details on outpatient care missing from two annual government reports: the National Healthcare Quality Report, and the National Healthcare Disparities Report. These reports collectively documented both a substandard level of care from providers across the country, and a pervasive gap in quality between whites and minorities. For example, the disparities report found that minorities are more likely than whites to die from HIV/AIDS, and they are also less likely to receive routine childhood immunizations.
While their study confirms a suboptimal quality of outpatient care overall, Ma and Stafford were surprised by the results regarding equality of care. "When we set out to do the study, we expected to see these disparities," Ma said. "But our result was contrary to our hypothesis."
The researchers compared outpatient data from 1992 and 2002, broken down by race and ethnicity. Of 23 quality measures designated by the researchers, such as appropriate prescription of antidepressants and dietary counseling for example, only two showed significant statistical differences with regard to race. First, blacks were more likely to receive angiotensin-converting enzyme inhibitors to treat congestive heart failure, and whites were less likely to receive unnecessary antibiotics to treat common colds.
As unexpected as this result might be, it does not mean that racial and ethnic health-care disparities do not exist, Ma cautioned. "A lack of statistical significance does not automatically mean there is a lack of clinical or political significance," she said. "It is a very complex issue."
Ma added that the study does not provide any information about initial access to health care, since outpatient information accounts only for patients who have already accessed the system. This might be an important distinction. "We speculate that racial and ethnic disparities may arise more from unequal health-care access and utilization than from direct differences in treatment once a patient is in the system," she said.
This gap in access and use could be due to many factors. For example, minorities might have difficulty communicating effectively with their health-care provider, they might lack access to educational materials or they might not have adequate insurance coverage to begin with, Ma said.
To better understand the problem, she believes there are several important questions to ask. First, what underlying factors stand in the way of equitable access to health coverage? Second, why do patients with adequate insurance coverage not seek treatment when it is needed? Third, why do patients sometimes fail to return for proper follow-up care?
So far, no study has been able to offer a clear explanation as to what causes disparities in health care - either in terms of access or treatment quality. To answer this question, Ma suggests more research. The key, she said, is more detailed data that better represent the nation's minority populations as a whole, not just those who receive outpatient care. She also sees the need for data that follow individual patients through an entire treatment cycle, from first visit to final outcome, to help understand where and why disparities exist and how they can be eliminated.
Stanford University Medical Center integrates research, medical education and patient care at its three institutions - Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children's Hospital at Stanford. For more information, please visit the Web site of the medical center's Office of Communication & Public Affairs at http://mednews.stanford.edu.
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