Are all patients created equal? Kevin A Schulman MD Director, Center for Clinical and Genetic Economics Duke Clinical Research Institute Duke University Medical Center Durham, NC

Treatment and race Treatment a heart patient receives may depend partly on the race of the patient. Insurance may be related to these differences in access in procedures. However, recent studies have suggested that even for patients in the same healthcare system, blacks are still less likely to receive cardiac procedures than whites for a given diagnosis.

Survival and race One study demonstrated that differences in procedure rates directly contributed to differences in survival for patients with cardiovascular disease. Peterson ED, et al. N Engl J Med 1997;336(7): Among patients with cancer, a recent study showed that differences in access to lung cancer surgery for patients with resectable non-small-cell lung cancer (stage I or II) contributed to better survival by white than black patients. Bach PB, et al. N Engl J Med 1999;341(16):

Lung cancer treatment Participants were black and white patients, 65 years of age or older, who were given a diagnosis of resectable non-small-cell lung cancer (stage I or II) between 1985 and 1993 and who resided in 1 of the 10 study areas of the Surveillance, Epidemiology, and End Results (SEER) program. Data on the diagnosis, stage of disease, treatment, and demographic characteristics of the patients were obtained from the SEER database. Information on coexisting illnesses, type of Medicare coverage, and survival was obtained from linked Medicare inpatient-discharge records. Study design Bach PB, et al. N Engl J Med 1999;341(16):

Lung cancer treatment Among those undergoing surgery, survival was similar for the 2 racial groups; the same was true among those who did not undergo surgery. The lower survival rate among black patients with early- stage non-small-cell lung cancer than among white patients may by largely explained by the lower rate of surgical treatment among blacks. Efforts to increase the rate of surgical treatment for black patients may improve survival in this group. Results and conclusions Bach PB, et al. N Engl J Med 1999;341(16): Black patients White patientsp value Rate of surgery64.0%76.7%p< year survival rate26.4%34.1%p<0.001

CVD procedure rates Duke University study of patients with coronary disease (10.3% were black). Outcome measures whether racial differences in the use of coronary angioplasty and bypass surgery were evident among patients with documented coronary disease on cardiac catheterization whether differences in clinical history, severity of disease, anginal symptoms, coexisting illness, or access to cardiovascular care in subspecialties accounted for the treatment differences the use of revascularization procedures in blacks and whites as a function of the underlying severity of angina and the estimated survival benefit due to the procedures comparison of unadjusted and adjusted long-term survival rates among blacks and whites Study design Peterson ED, et al. N Engl J Med 1997;336(7):

CVD procedure rates After adjustment for the severity of disease and other characteristics, black patients were 13% less likely than white patients to undergo angioplasty and 32% less likely to undergo bypass surgery. The adjusted black:white odds ratios (OR) for receiving these procedures were 0.87 (95% CI, 0.73 to 1.03) for angioplasty and 0.68 (95% CI, 0.56 to 0.82) for bypass surgery. The racial differences in rates of bypass surgery persisted among those with severe anginal symptoms (31% of black patients underwent surgery vs 45% of white patients; p<0.001) and among those predicted to have the greatest survival benefit from revascularization (42% vs 61%, p<0.001). Unadjusted and adjusted rates of survival for 5 years were significantly lower in black than in white patients. Study results Peterson ED, et al. N Engl J Med 1997;336(7):

CVD procedure rates Black patients with coronary disease were significantly less likely than white patients to undergo coronary revascularization, particularly bypass surgery — a difference that could not be explained by the clinical features of their disease. The differences in treatment were most pronounced among those predicted to benefit the most from revascularization. These differences also correlated with a lower survival rate in black patients; therefore coronary revascularization appears to be underused in this population. Study conclusions Peterson ED, et al. N Engl J Med 1997;336(7):

Kidney transplantation 1392 patients: 384 black women, 354 white women, 337 black men, and 317 white men Patients with end-stage renal disease (age range = 18 to 54 years) were interviewed approximately 10 months after they had begun maintenance treatment with dialysis. Participants were selected from a stratified random sample of patients undergoing dialysis in 4 regions of the United States (Alabama, southern California, Michigan, and the mid-Atlantic region) in 1996 and Patients were followed until March Study design Ayanian JZ, et al. N Engl J Med 1999;341(22):

Kidney transplantation Patients wanting a transplant: 76.3% of black women vs 79.3% of white women; 80.7% of black men vs 85.5% of white men Patients very certain about this preference: 58.3% for black women vs 65.3% for white women; 64.1% for black men vs 75.7% for white men (p<0.01 for each comparison with both sexes combined) Rates of referral for transplantation evaluation: 50.4% for black women vs 70.5% for white women; 53.9% for black men vs 76.2% for white men (p<0.001 for each comparison). Placement on a waiting list or transplantation within 18 months of beginning dialysis: 31.3% for black women vs 56.5% for white women; 35.3% for black men vs 60.6% for white men (p<0.001). These differences remained significant after adjustment for patient preference and expectations about transplantation, sociodemographic characteristics, the type of dialysis facility, perceptions of care, health status, cause of renal failure, and the presence or absence of coexisting illnesses. Study results Ayanian JZ, et al. N Engl J Med 1999;341(22):

Kidney transplantation In the United States, the preferences and expectations with respect to kidney transplantation among patients with end-stage renal disease differ according to race. These differences, however, explain only a small fraction of the substantial racial differences in access to transplantation. Physicians should ensure that black patients who want kidney transplantation are fully informed about it and are referred for evaluation. Study conclusions Ayanian JZ, et al. N Engl J Med 1999;341(22):

Cardiac catheterization Interviews were recorded in which actors portrayed patients with scripted characteristics and symptoms. 720 physicians viewed a recorded interview and were given other data about the hypothetical patient; the physicians then made recommendations about that patient's care. A computerized survey assessed the physicians' recommendations for managing chest pain. Multivariate logistic-regression analysis was used to assess the effects of the race and sex on treatment recommendations, while controlling for physician assessment of the probability of coronary artery disease and for the age of the patient, level of coronary risk, type of chest pain, and results of an exercise stress test. Study design Schulman KA, et al. N Engl J Med 1999;340(8):

Cardiac catheterization The mean (±SD) estimates of the probability of coronary artery disease were lower for women (64.1±19.3% vs 69.2±18.2% for men; p<0.001), younger patients (63.8±19.5% for patients who were 55 years old vs 69.5±17.9% for patients who were 70 years old; p<0.001), and patients with nonanginal pain (58.3±19.0% vs 64.4±18.3% for patients with possible angina and 77.1±14.0% for those with definite angina; p<0.001). Logistic-regression analysis indicated that women (OR=0.60; 95% CI=0.4 to 0.9; p=0.02) and black patients (OR=0.60; 95% CI=0.4 to 0.9; p=0.02) were less likely to be referred for cardiac catheterization than men and white patients. Analysis of race-sex interactions showed that black women were significantly less likely to be referred for catheterization than white men (OR=0.4; 95% CI=0.2 to 0.7; p=0.004). Study results Schulman KA, et al. N Engl J Med 1999;340(8):

Cardiac catheterization The race and sex of a patient may independently influence the way physicians manage chest pain. Decision-making by physicians may be a factor in explaining differences in the treatment of cardiovascular disease with respect to race and sex. Study conclusions Schulman KA, et al. N Engl J Med 1999;340(8):

Medical students' ratings The influence of race and sex on medical students' perceptions of patients' symptoms were evaluated to determine whether there are differences in these perceptions early in medical training. 164 medical students were randomly assigned to view a video of a black female or white male actor portraying patients with identical symptoms of angina. Students' perceptions of the actors' health state (based on their assessment of quality of life) were evaluated using a visual analog scale and a standard rating technique; the type of chest-pain diagnosis was also evaluated. Study design Rathore SS, et al. Am J Med 2000;108(7):

Medical students' ratings Students assigned a lower value (indicating a less desirable health state) to the black woman than to the white man (mean visual scale score±SD: 72±13 vs 67±12, p<0.02; standard gamble: 87±10 vs 80±15, p<0.001). Nonminority students reported a higher mean value for the white male patient (standard gamble: 89±8 vs 81±14 for the black female patient), whereas minority students' assessments did not differ by patient. Male students assigned a slightly lower value to the black female patient (standard gamble: 76±16 vs 87±10 for the white male patient). Students were less likely to characterize the black female patient's symptoms as angina (46% vs 74% for the white male patient, p=0.001). Study results Rathore SS, et al. Am J Med 2000;108(7):

Medical students' ratings The way that medical students perceive patient symptoms appears to be affected by nonmedical factors. Physicians are actually no different than anyone else, in that they have attitudes about people of other races, other socioeconomic status that effect treatment recommendations. Although physicians are not responsible for all the differences in treatment recommendations that we find in the epidemiologic literature, there is no reason for there to be any contribution by physicians to these processes. Study conclusions Rathore SS, et al. Am J Med 2000;108(7):

Improving curricula As physicians, we have to admit that we carry these biases and learn how to deal with them. Legislation currently before Congress would provide an opportunity to test how to implement the curriculum, how to evaluate how effective we are in doing that, and evaluate whether or not students are responding to the educational messages. Section 402 of the Health Care Fairness Act of 1999 Not later than 1 year after the date of enactment of this Act, the Secretary of Health and Human Services shall convene a national conference on continuing medical education as a method for reducing disparity in health care and health outcomes, including continuing medical education on cultural competency. The conference shall include sessions to address measurements of outcomes to assess the effectiveness of curricula in reducing disparity.

AMA policy The AMA has some policy statements calling for training on the part of practicing physicians. AMA Policy H (AMA Policy Compendium) expresses zero tolerance of the clearly identified racial and ethnic disparities in health care. Policy H and Council on Ethical and Judicial Affairs Opinion E (AMA Policy Compendium) stress that academic and other medical institutions should offer educational programs about gender and cultural issues to staff, physicians in training, and students. These policies reflect the Association’s understanding that knowledge and tolerance of cultural diversity is integral to effective health care delivery and that it must encourage physicians and health care organizations to respond to the social, cultural, economic, and political diversity of their communities, including serious consideration of cultural solutions to illness. Cultural sensitivity training

A changing community The community physicians are practicing in today is less homogeneous than it was when many physicians were trained, and it is going to become increasingly heterogeneous in the future. Until an effective curriculum is established, most physicians are reluctant to have such training mandated. Ideally, all physicians should look at their own practices and think about ways to understand their failings as providers and explore ways to overcome such failings.