Researchers find ‘racially unequal care’ in most outpatient practices
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Racial and ethnic minority groups were “markedly underrepresented” in outpatient practices across most medical specialties, and those disparities persisted even after researchers accounted for social determinants of access to care.
“Two previous studies found that Black and Hispanic Americans had low rates of visits to neurologists, and that minority youth received much less psychiatric care than white youth,” Stephanie Joan Woolhandler, MD, MPH, a lecturer in the department of medicine at the Cambridge Health Alliance, told Healio Primary Care. “However, this is the first study to look at all major physician specialties and to document racially unequal care for most of them.”
The researchers gathered office and outpatient visit information from the 2015 to 2018 Medical Expenditure Panel Survey. Their analysis included 132,423 adults (60% white, 17.7% Hispanic, 12.3% Black, 6.1% Asian, 0.8% Native American and remaining identified as other). The survey does not include “detailed clinical metrics” that could be used to tabulate patient outcomes, and it relies on patients to report the type of specialist care they received, according to the researchers.
Woolhandler and colleagues reported that Black patients had low visit rates in 23 of 29 medical specialties compared with white patients, who had a low visit rate in 17 of the 29 specialties. Black-white disparities were most pronounced in specialties with many visits, including dermatology (adjusted rate ratio = 0.27; 95% CI, 0.21-0.34), otolaryngology (aRR = 0.38; 95% CI, 0.32-0.46), plastic surgery (aRR = 0.41; 95% CI, 0.23-0.75), general surgery (aRR = 0.55; 95% CI, 0.44-0.69), orthopedics (aRR = 0.59; 95% CI, 0.51-0.69), urology (aRR = 0.62; 95% CI, 0.5-0.78) and pulmonology (aRR = 0.63; 95% CI, 0.48-0.81). In contrast, Black patients had higher visit rates than white patients to nephrologists (aRR = 2.78; 95% CI, 1.37-5.62) and hematologists (aRR =1.65; 95% CI, 1-2.7). Visit rates to internists, geriatricians and oncologists were similar between Black and white patients.
Compared with white patients, Hispanic patients had significantly lower visit rates for 20 of the 29 specialties, and Asian/Pacific Islander patients had low visit rates for 21 of 27 specialties. “Similar patterns were present for Native American individuals, although the 95% CIs were wide,” the researchers wrote.
Results also showed that Hispanic patients had specialty office visit rates that were “markedly low” when compared with white patients for dermatology (aRR = 0.39; 95% CI, 0.33-0.46), otolaryngology (aRR = (0.47; 95% CI, 0.39-0.56) and pulmonology (aRR = 0.55; 95% CI, 0.4-0.77). The aRRs for Asian/Pacific Islander patients compared with white patients were “markedly low” for hematology (0.18; 95% CI, 0.08-0.39), pulmonology (0.26; 95% CI, 0.15-0.45) and otolaryngology (0.39; 95% CI, 0.31-0.48).
The findings remained mostly consistent when the researchers adjusted for sex, self-reported health, health insurance, education level and income. The aRRs for Black vs. white patients in these models were 0.34 for dermatology (95% CI, 0.26-0.43), 0.35 for plastic surgery (95% CI, 0.21-0.59), 0.43 for otolaryngology (95% CI, 0.34-0.54), 0.54 for general surgery (95% CI, 0.42-0.69), 0.63 for orthopedics (95% CI, 0.54-0.74), 0.63 for urology (95% CI, 0.51-0.78) and 0.56 for pulmonology (95% CI, 0.4-0.77).
“In other words, most medical specialists deliver disproportionately fewer visits to patients of color,” study co-author Christopher Cai, MD, a clinical fellow in medicine at Brigham and Women’s Hospital, told Healio Primary Care.
Woolhandler suggested that many physicians are asking themselves what they can do about systemic racism.
“Our profession can start by getting our own house in order, and assuring that all patients have equal access to our offices and clinics,” she said.
Cai agreed, describing the findings as a “call to action.”
“Our study highlights the need for physicians to do more to address the effects of structural racism: differences in insurance, referral systems, practice locations and other factors which lead patients of color to have worse health outcomes,” he said.
Cai also encouraged physicians to increase training opportunities and introduce policies that increase access to specialist care among underrepresented populations.