Understanding the dynamics between ethnicity and health care: Another role for health services research in chronic disease management

Field: Health Professions (Health Sciences)

Health care issues continue to be hotly debated from rural America to Capitol Hill. Throughout these discussions and debates, the essential issues remain the same: the quality and cost of health care, and access to health care. During the decade of the 1990s, America embraced managed care, some would say managing the cost of care. That experience sharpened our perceptions of what constitutes quality health care and what that health care might cost. During that same time, numerous studies explored disparities in access to health care. Health services researchers identified many barriers or inequities regarding access to care. Such barriers include economic factors, ethnic bias or prejudice in the delivery of health care, trust between patients and their providers or the health system itself, disease factors, risk aversion among ethnic groups, and patient preferences. In all likelihood, all of these factors play some role in patients' perceptions and preferences about their health care needs and choices. Disparities in access to health care and use of health services is a persistent public policy problem. Eliminating ethnic disparities in health care definitely occupies center stage on the federal government's agenda. In 1998, the Initiative to Eliminate Racial and Ethnic Disparities in Health was introduced, and soon, new goals to reduce ethnic disparities were added to the Healthy People 2010 goals (1). This policy priority recently received added prominence when the National Institutes of Health established the National Center for Research on Minority Health and Health Disparities. The Department of Veterans Affairs (VA), with its commitment to equal access and quality health care for all veterans, has as a compelling goal: the elimination of ethnic disparities in health care. Minorities constitute 8% of the veteran population, and this number will grow as the ranks of the armed forces, 20% of whom are minorities, join America's veterans. The VA is not a newcomer to the challenge of identifying, understanding, and eliminating ethnic disparities in health care. In 1994, the VA established the Center for Minority Veterans in the Office of the Secretary. The VA has been at the forefront of efforts to advance research on ethnic disparities in health care, with studies in the early 1990s identifying ethnic differences in the use and outcomes of medical procedures for stroke and other cardiovascular diseases (2-4). This issue of Arthritis & Rheumatism includes a research report from Ibrahim and colleagues that addresses a facet of this difficult problem of access to or use of health care services by ethnic minorities (5). Ibrahim et al explore patients' expectations of medical care and compare the “willingness” of African American and white patients with severe osteoarthritis (OA) of the hip or knee to consider joint replacement surgery. The investigators remind us that joint replacement surgery is cost-effective. Overwhelmingly, patients experience symptomatic and functional improvement after artificial hip or knee replacement. The procedure has a low risk profile and is perceived by health care professionals as safe. Furthermore, the intervention is durable. Under such circumstances, most physicians would recommend that appropriately selected patients undergo surgery. They would expect that patients who have sufficient pain and poor mobility would accept this elective surgical procedure. However, Ibrahim et al appropriately chose to study the other side of this issue—what patients may expect and what they may be “willing” to do to reduce their pain and suffering. Interestingly, few other studies explore this aspect of health care delivery using an approach similar to that of Ibrahim and colleagues. However, this line of research, exploring the interface between the patient, the provider, and the health system, may better help us to help our patients by enhancing our understanding of what they think, what they value, and what they might be “willing” to accept or risk (5). Ibrahim and colleagues have completed an important piece of health services research, and they have done their work well. Their research explores patient preferences and “willingness” to accept surgical interventions in real time with questions put to real patients with significant OA. They are not constrained by information contained in administrative databases. The investigators have carefully chosen their study patients to reflect those who might actually consider surgery for their OA. The sample of patients studied is appropriate to the research question and is sufficiently large to address the question with statistical precision. Importantly, patients who volunteered for the study identified their own ethnicity. Their disease was assessed radiographically by “blinded” observers using an explicit scoring system. Other measures used in the study reflect the reliability inherent in instruments of known validity and variability, such as the Lequesne Scale (6), the Western Ontario and McMaster Universities Osteoarthritis Index (7), and the Charlson Comorbidity Index (8). The statistical analysis was specified a priori, as were clinically significant cut points used in the analysis, and appropriate multivariate modeling was used to control for potential confounders (5). Ibrahim and colleagues found differences between African American and white patients in sociodemographic variables, familiarity with surgery, and “willingness” to accept (or risk) the surgical procedure. Their results are not only interesting, they are also useful in suggesting clinical strategies that inform patients adequately about the benefits and risks of hip or knee replacement surgery. Ibrahim et al also identified some limitations of their research. They studied only men. Perhaps their results, while valid in men, may not extend to women, who are typically more intensive users of health services. There are other studies that explore issues of ethnicity and access to health care that are not limited by gender considerations (9-11). Ibrahim et al studied patients in the VA, an economically neutral, federally funded health care system. This might limit generalizability to the remainder of the US, where economic considerations (or even access to basic health care) may be more complicated than for veterans. However, does this latter factor really limit the value of their research? Perhaps the VA health system presents an opportunity to study issues such as ethnicity, patient preferences and expectations, and the doctor–patient relationship unencumbered by economic inequities that complicate access to health care outside the VA. Rather than being viewed as a limitation, can health services research in such a publicly supported health system actually provide some lessons for other components of the US health care delivery patchwork? The VA cares for a defined patient population (mostly men); has clear and ready access to health care services; delivers quality care at an acceptable cost; has excellent databases, including a computerized patient medical record; and has made elimination of ethnic disparities in health care a health services research priority, at least since 1996 (12). To my way of thinking, this seems to provide more opportunities than limitations. The results of the current study are encouraging and suggest that the VA health system has moved beyond financial barriers and ethnic prejudices to identify issues of patient understanding and preferences that may be more tractable clinically. Findings of recent studies support such an inference. Jha and colleagues studied ethnic differences in mortality among men hospitalized in the VA health system (13). Those investigators studied 6 common medical diagnoses, including pneumonia, angina, congestive heart failure, chronic obstructive pulmonary disease, diabetes, and chronic renal failure. Their findings were intriguing, suggesting that African Americans, compared with white Americans, have a lower mortality rate from these illnesses. At least, they found no survival disadvantage among this minority group in the VA health system. More recently, the VA organized a special symposium focused on understanding ethnic disparities in access to and use of health care services (12, 14). Results from these 13 studies are too extensive to discuss in the context of this article, but they do merit attention from other health services researchers interested in this issue, as well as from Washington policymakers struggling with the persistent problem of health care equity. One must commend the high-quality research by Ibrahim and colleagues reported in this issue of Arthritis & Rheumatism. I question only their concern that the unique features of the VA health system represent a limitation of the external validity of their research. What might the next steps be to extend their studies beyond the VA and that perceived limitation? The federal research establishment could initiate a sustained program of research that systematically conducts comparative health systems studies. Additional research could be done simultaneously in publicly funded health systems like the VA; in academic health systems, where much health care is delivered to underserved minorities; and in nonacademic community hospitals, except for those that exclude underserved patients. Such comparative work is feasible and would provide concrete comparative systems analyses that would eliminate concerns about the generalizability of the resultant research findings. Such comparative health systems research might even move the US beyond policy debates to actions that change health care delivery, improve access to health care, and establish equity in health care as a national goal.