WASHINGTON – Health care disparities among ethnic groups should be considered a form of medical error, James Gavin, M.D., said at a consensus conference on patient safety and medical system errors in diabetes and endocrinology.
“When we see disparities, that really is a reflection of inadequate patient safety,” said Dr. Gavin, who is past president and professor of medicine at Morehouse School of Medicine, Atlanta. “It means that under the same or similar conditions of risk or exposure, the outcomes are sufficiently different that there is some disadvantage conferred on one of the other subject populations.”
One example is coronary heart disease (CHD), he said at the conference, sponsored by the American Association of Clinical Endocrinologists. “There is a real difference in CHD mortality in black males, compared with whites at every age stratum; it doesn't start to even out until you get to the ninth decade of life. I'd be very concerned about these kinds of numbers.”
Results like these are in part a reflection of how medical decisions are made for different patients, and, sometimes, the only way to get at that information is by looking at surrogates for decision making, such as utilization rates, Dr. Gavin said.
For instance, coronary artery bypass graft surgery (CABG) has proved to be of significant benefit in high-risk patients, and yet “CABG is significantly underutilized in blacks, compared with whites,” he said. On the other hand, data on amputation among patients with diabetes “suggest it is significantly more utilized in blacks, compared with whites. Something is driving these outcomes.”
Part of the problem may be bad information, he suggested. A report from a commission chartered in the 1980s by Health and Human Services Secretary Margaret Heckler found several myths about heart disease in black patients, including the idea that black patients rarely had myocardial infarctions or angina, or that they were immune to CHD.
“Because of flaws in the way data were interpreted, they were actually underreporting CHD as a cause of death, when … CHD was actually the leading cause of death in U.S. blacks then just as it is now,” Dr. Gavin noted.
Now that researchers are looking at disparities more systematically, they are finding that even when minorities have access to health care that is equivalent to that of white patients, there is still an inequity in the services they receive, he said.
“That part of the gap that is attributable to patient needs and patient preferences you have to back out [of the equation] because you can't blame a patient's choice,” he said. “But these other issues, the way the system operates, the way individual and group biases and prejudices [affect things], those issues are major drivers.”
Medicare data on diabetes care show that something is clearly “amiss,” he continued. “For example, despite the greater prevalence and risk associated with it, African Americans are less likely to undergo hemoglobin A1c testing, or to have their lipids tested, or to have vaccinations. And this is in the Medicare population, where coverage is not the issue.”
In another instance of disparities in diabetes care, “African Americans are 12% of the population, but fully a third or more of the [end-stage renal disease] population,” he said. “They also are less likely to receive a kidney transplant and less likely to be referred for a transplant, or to be placed on a transplant waiting list. Those are decisions that someone has to make.”
Some of the disparities arise from the clinical encounter itself. “It's at that level we have to begin to pay more attention because it is only to the extent that we improve the quality of this encounter …that we will begin to influence this process,” Dr. Gavin said. “There will be less ambiguity, less misunderstanding, and we'll begin to mitigate the influence of prejudices, no matter who brings them to the table.”
Dr. Gavin said he didn't agree with the idea of “cultural competency.” “It's not something I'm convinced we ever become competent at. It's always a work in progress. But [we] can work to become more self-aware of our own cultural norms and values that will quickly lead us to misjudge or miscommunicate with others.”
One problem with cultural competency training, for instance, is that it can confer a false level of confidence, he noted. “We think we can go to one workshop and come out culturally competent, when in fact it's lifelong learning. And we have to be careful not to reinforce cultural stereotypes.”