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Editor's Note
In Focus Health Highlights
International Health

Fall 2002; Volume 3, Number 2
Features: Equality and Health Care

"Unequal Treatment": The Institute of Medicine's Findings and Recommendations on Healthcare Disparities
Joseph Betancourt, MD, MPH
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In 1999, the United States Congress commissioned the Institute of Medicine (IOM) to study the issue of racial and ethnic disparities in health care. The federal government realized that: (1) racial and ethnic minorities have benefited less from overall improvements in Americans' health over the past century; and (2) despite interventions to equalize population health, racial/ethnic disparities exist in the quality of health care patients are receiving. This paper summarily charts the IOM's landmark study, entitled "Unequal Treatment," and concludes with its recommendations for eliminating racial/ethnic disparities in health care.

Commissioning the IOM Report "Unequal Treatment"

Data show that minority Americans suffer disproportionately from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer, and HIV/AIDS, among others.[1] A wide body of literature documents the adverse impacts of social determinants (i.e., low education levels, inadequate and unsafe housing, high unemployment rates, and low socioeconomic status) on minority populations' health outcomes. [2-6] Similarly, research has correlated lack of access to medical care with poorer health status, [7,8] and illustrated the prolonged impact of racism on health.[9,10]

In 1998, as part of his "Initiative on Race," President Clinton set forth the goal of eliminating racial/ethnic disparities in health in the United States. The "Initiative" focused the Department of Health and Human Services on eliminating disparities in cardiovascular disease, diabetes, cancer screening and management, HIV/AIDS, infant mortality, and immunization rates by the year 2010. Among the most notable of its efforts in research and programmatic grantmaking thus far have been the Agency for Healthcare Research and Quality's funding of "Excellence Centers to Eliminate Ethnic/Racial Disparities" (EXCEED), and the Center for Disease Control's "Racial and Ethnic Approaches to Community Health" (REACH) projects. EXCEED grants provided $45 million in research funding, while REACH grants focused on community-based efforts to eliminate racial/ethnic disparities in health.

Despite significant progress in addressing racial/ethnic health disparities, equally concerning is the emerging literature on racial/ethnic disparities in quality of care for those with access to the medical system. Such disparities have been recognized in the utilization of cardiac diagnostic and therapeutic procedures, [11-15 prescription of analgesia for pain control, [16-18] surgical treatment of lung cancer,[19] referral to renal transplantation,[20] treatment of pneumonia and congestive heart failure,[21] and the utilization of general services covered by Medicare (i.e. immunizations and mammograms),[22] even when variations in factors such as insurance status, income, age, co-morbid conditions, and symptom expression are taken into account. Whereas racial/ethnic disparities in health were deemed "unacceptable yet understandable" given the persistent racial and socioeconomic inequalities in the US today, the racial/ethnic disparities in health care highlighted by this research seemed unconscionable.

As a result, in 1999 the United States Congress commissioned the Institute of Medicine (IOM) to take on and study the issue of racial/ethnic disparities in the healthcare system. The IOM, part of the National Academy of Sciences and chartered by Congress to advise the Federal Government on issues of health policy, medical care, research, and education, was asked to: (1) assess the extent of racial/ethnic differences in health care that are not otherwise attributable to known factors like access to care (e.g., ability to pay or insurance coverage); (2) evaluate potential sources of racial and ethnic disparities in health care, including the role of bias, discrimination, and stereotyping at the individual (provider and patient), institutional, and health systems levels; and (3) provide recommendations regarding interventions to eliminate healthcare disparities.

Findings of the Report

To launch its assigned study, the IOM convened a committee of academicians, medical educators, health service researchers, health policy makers, economists, social psychologists, social scientists, lawyers, practicing physicians and nurses - some with experience and knowledge of disparities and others with expertise and proven leadership in other aspects of healthcare delivery and research. Given that the charge of the committee was limited to disparities in health care (versus the larger issue of health outcomes), specific areas of exploration included health system factors (financial and institutional arrangements, structural processes of care, etc.), provider factors (communication in the medical encounter, the effect of race/ethnicity on clinical decision-making, etc.), and consumer factors (patient preferences).

To complete the study in 18 months, the committee reviewed a significant amount of evidence from five main streams, including: a literature review (with strict inclusion and exclusion criteria), commissioned papers (on topics ranging from an exploration of health disparities to the economic, ethical and legal ramifications of disparities in health), expert testimony, focus groups of patients and providers, and a public workshop. The final report, entitled "Unequal Treatment: Confronting Racial/Ethnic Disparities in Healthcare"[23] was released on March 20, 2002. The report's major findings state that:

  • Racial and ethnic disparities in health care exist, and are unacceptable because they are associated with worse health outcomes.
  • Racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequalities, and evidence of persistent racial and ethnic discrimination exists in many sectors of American life.
  • Many sources - including health systems, healthcare providers, patients, and utilization managers - may contribute to racial and ethnic disparities in health care.
  • Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in health care.
  • A small number of studies suggest that certain patients may be more likely to refuse treatments, yet these refusal rates are generally small and do not fully explain healthcare disparities.

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Joseph Betancourt, MD, MPH is a Senior Scientist at the Institute for Health Policy and Director of Multicultural Education at Massachusetts General Hospital-Harvard Medical School. He served on the IOM Committee on Understanding and Eliminating Racial/Ethnic Disparities in Health Care responsible for the publication of "Unequal Treatment."

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