Race/Ethnicity and Overuse of Care: A Systematic Review

“Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge,” according to the Institute of Medicine's Crossing the Quality Chasm.1 Yet the evidence clearly shows that racial and ethnic minority patients often do not receive necessary and appropriate health care.2,3 This “underuse” of care among racial and ethnic minorities (depicted in the southeast quadrant of Figure ​Figure1)—especially1)—especially in contrast to white patients’ receipt of appropriate and necessary care (northeast quadrant)—is commonly referred to as “disparities” in care. Figure 1 An Individual Patient's Appropriateness for and Likelihood of Receiving a Certain Form of Care At the same time, it is increasingly clear that a sizable proportion of health care in the United States is “unnecessary”—that is, patients are receiving care that they do not need, which does not improve their health outcomes, and which may expose them to harm and risks,4 a situation referred to as the “overuse” of care (northwest quadrant of Figure ​Figure1).1). While much has been written about the geographic, health-systems, clinician, and payer factors associated with the overuse of care,5–8 less is known about the extent to which patients’ nonclinical characteristics, including sociodemographic factors like race/ethnicity, are associated with overuse.9 There are several indications that patient race/ethnicity might be related to overuse of care. Because patients’ attitudes, beliefs, and trust in medicine vary by race/ethnicity, these could differentially affect their risk for overuse. For example, white patients have greater “medical technology innovativeness,” more positive attitudes toward and receptivity to new drugs, devices, or procedures,10 which might contribute to their greater acceptance of and eagerness to obtain such therapies. In contrast, black patients have more pessimistic expectations of surgical outcomes, even for procedures like joint replacement with well-established efficacy, than do whites.11 While financial barriers are known impediments to the receipt of care,12–14 the converse may be true in that well-insured and affluent patients may be at increased risk for overuse.15 To the extent that whites, on average, are more optimistic about the health care system's ability to diagnose and cure them, and also have more financial resources to pay for care, this ironically may result in racial disparities in care in which white patients are at greater risk for overdiagnosis and overtreatment. Clearly, patients are not the only potential drivers of overuse, given the many system- and clinician-level factors beyond their control. For example, receiving care in a region with practice patterns of more frequent visits, a greater use of hospital care and intensive care units, a greater supply of specialists and hospital beds,16,17 and greater physician investment in diagnostic testing centers or hospitals18 predisposes patients to receive more care than they would in areas with different characteristics. Conversely, the concentration of minority patients at institutions or with providers with fewer resources and cutting-edge technologies,19,20 besides impeding access to needed care, could also reduce the likelihood of their overusing newer diagnostic and therapeutic care with little marginal value over older therapies. These suppositions motivated us to conduct a systematic review of the medical literature to evaluate what is known about the relationship between patients’ race/ethnicity and their overuse of care.