CHICAGO — Health care disparity in rheumatic disease stems from multiple sources, not just the patient's race or the physician's bias.
Disease incidence and prevalence, access to care, choice of provider and health system, and individual patient preferences can all contribute to disparity, said Dr. Agustin Escalante, professor of medicine and clinical immunology at the University of Texas Health Science Center in San Antonio. Besides, concepts of race are often invalid.
“The traditional concept of race assumes or proposes a small number of defined groups (whites, blacks, Asians, among others) but in fact you don't have the discrete groups the traditional concept assumes,” said Dr. Escalante.
Hispanics, for example, may have European, Asian, or African ancestry, with disease consequences. A 2003 study found the risk of systemic lupus erythematosus in a Caribbean population to be associated with West African admixture (Hum. Genet. 2003;112:310-8).
As to physician bias, “nobody goes into medical school to set up an apartheid system in their clinics,” said Dr. Escalante. But bias can still creep in.
A 1999 study used actors of different races and sexes to portray patients with cardiac and noncardiac chest pain and found that women and African-Americans were less likely than white males to be referred for catheterization (N. Engl. J. Med. 1999;340:618-26).
Alternatively, health disparity can simply be a matter of access to care. If a local physician does not accept Medicaid, the patient may have to travel a distance to find one who does. Insurance may likewise have an impact. A study of patients with rheumatoid arthritis found that those in an HMO were significantly less likely to receive anti–tumor necrosis factor agents than were those who had fee-for-service policies (Arthritis Rheum. 2005;53:423-30).
Language may also have an impact on disparity. A study of pain in the emergency department found that Hispanics were much less likely to receive analgesics than were whites after long-bone fractures (Pain Manag. Nurs. 2008;9:26-32).
“If the patient doesn't speak English and the doctor is uncertain what's going on with them, it will take longer to decide,” said Dr. Escalante.
But the main source of health disparity, according to Dr. Escalante, is patient preference and willingness or unwillingness to receive treatment. A 1995 study found that blacks were half as likely to receive hip replacements as were whites, and Hispanics were one-seventh as likely, despite all patients' being insured with Medicaid (Ann. Rheum. Dis. 1995;54:107-10). A study of referrals found that patients were referred irrespective of race (Arthritis Rheum. 2009;61:1677-85).
A study of preferences for joint replacement for knee arthritis found that for those with severe arthritis, more whites and Hispanics chose total knee arthroplasty than did blacks, by far (J. Clin. Epidemiol. 2006;59:1078-86).
Knowledge was not necessarily a factor: When asked whether they had heard of the procedure before, 100% of whites said yes, compared with 90% of blacks and 80% of Hispanics (Arch. Intern. Med. 2005;165:1117-24).
“Studies have shown that African-Americans tend to be more fearful of the complications of total knee replacement, and they tend to underestimate the benefits,” said Dr. Escalante.
Dr. Escalante concluded by saying that the simplest way to think about cultural competency is language. Symposium chair Dr. John J. Cush, professor of medicine and rheumatology at Baylor University Medical Center, Houston, asked what one bit of advice he would give the audience.
“Everybody could learn Spanish,” said Dr. Escalante.
Disclosures: Dr. Escalante reported no relevant financial interests. The study was sponsored by the University of Texas Health Science Center at San Antonio. Dr. Cush disclosed consulting fees or other remuneration from Centocor Inc., Abbott Laboratories, UCB, Pfizer Inc., Wyeth/Amgen Inc., and Roche, and research grants from Genentech Inc., Pfizer, UCB, Roche, and Celgene Corp.