The effect of race and sex on physicians' recommendations for cardiac catheterization

Severity of coronary artery disease in black and white male veterans and likelihood of revascularization

BACKGROUND

Many reports in the literature have found the use of invasive cardiac procedures in black patients to be less common than in white patients. These reports tend to have small numbers of black patients compared with white patients or rely on the information contained in claims or administrative data.

METHODS AND RESULTS

Cardiac catheterization reports were reviewed in a Veterans Administration hospital that serves a large number of black patients. After review of the medical histories and hemodynamic and angiographic findings in 726 black and 734 white male veterans, data were collected to determine recommended and actual therapy. Death was assessed after a 4- to 10-year follow-up period. White patients were more likely to have significant coronary artery lesions than black patients. Multivariate analysis showed that the likelihood of patients actually having percutaneous transluminal coronary angioplasty or coronary artery bypass surgery did not differ by ethnicity when controlling for disease extent or severity. Coronary artery bypass surgery was associated with decreased mortality rates for both black and white patients. Although short-term death in blacks was not different from whites, blacks had an increased long-term risk for death.

CONCLUSIONS

After coronary angiography, black veterans and white veterans appear to undergo revascularization procedures related to the severity of disease. The decreased long-term life expectancy of black men as compared with whites is not necessarily explained by the presence of or treatment for coronary artery disease in this population.

Impact of gender on access to the renal transplant waiting list for pediatric and adult patients

While the public and policy-makers place a priority on equity in the organ allocation process, several studies suggest that women may be less likely than men to receive a renal transplant. However, the cause of this disparity and whether it exists among children with end-stage renal disease (ESRD) are unknown. To address these issues, two nationally representative cohorts of incident patients were examined: (1) 7594 adults with ESRD onset between 1986 and 1993 for whom detailed data were available from the medical record on health status; and (2) 3217 patients <20 yr old who developed ESRD between 1988 and 1993. Patients were followed from initiation of dialysis for up to 10 yr until first activation on the United Network of Organ Sharing renal transplant waiting list. Access to the list for female and male patients with ESRD was compared using Cox proportional hazards models with adjustment for demographic, socioeconomic, and clinical factors. Crude rates of wait-listing per 100 person-years of ESRD were lower for female patients than male patients in both the pediatric (28.89 versus 34.18) and adult (3.94 versus 6.54) populations. Despite adjustment for numerous confounding factors, this gender-based disparity persisted in multivariate analysis. Among children with ESRD, female patients were 14% less likely to be listed than male patients (relative hazard [RH] 0.86; 95% confidence interval [CI], 0.78 to 0.93), and in the adult group, women were 18% less likely to be activated for transplant than men (RH 0.82; 95% CI, 0.72 to 0.93). These findings suggest that female patients of all ages with ESRD face barriers in being activated for cadaveric renal transplantation. Greater attention to this issue is necessary to improve equity in the organ allocation system and potentially improve the outcomes of female patients with ESRD.

Who gets chemotherapy for metastatic lung cancer?

STUDY OBJECTIVES

To determine the prevalence and factors associated with chemotherapy use in elderly patients presenting with advanced lung cancer.

DESIGN

A retrospective cohort study using administrative data.

SETTING AND PATIENTS

We analyzed the medical bills for the 6,308 Medicare patients > 65 years old with diagnosed stage IV non-small cell lung cancer (NSCLC) in the 11 SEER (survival, epidemiology, and end results) regions between 1991 and 1993. The main outcome measure, chemotherapy administration, was identified by the relevant medical billing codes. Patient sociodemographic and disease characteristics were obtained from the SEER database and census data.

RESULTS

Almost 22% of patients received chemotherapy at some time for their metastatic NSCLC. As expected, younger patients and those with fewer comorbid conditions were more likely to receive chemotherapy. However, several nonmedical factors, such as nonblack race, higher socioeconomic status, treatment in a teaching hospital, and living in the Seattle/Puget Sound or Los Angeles SEER regions, also significantly increased a patient's likelihood of receiving chemotherapy.

CONCLUSION

Compared to previous reports, the prevalence of chemotherapy use for advanced NSCLC appears to be increasing. However, despite uniform health insurance coverage, there is wide variation in the utilization of palliative chemotherapy among Medicare patients, and nonmedical factors are strong predictors of whether a patient receives chemotherapy. While it is impossible to know the appropriate rate of usage, nonmedical factors should only influence a patient's likelihood of receiving treatment if they reflect patient treatment preference. Research to further clarify the costs, benefits, and patient preferences for chemotherapy in this patient population is warranted in order to minimize the effect of nonmedical biases on management decisions.

Relation of race and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction

BACKGROUND

There are few reports describing the combined influence of the race and sex of a patient on the use of reperfusion therapy for acute myocardial infarction.

METHODS

To determine the relation of race and sex to the receipt of reperfusion therapy for myocardial infarction in the United States, we reviewed the medical records of 234,769 Medicare patients with myocardial infarction. From these records we identified 26,575 white or black patients who met strict eligibility criteria for reperfusion therapy. We then performed bivariate and multivariate analyses of prevalence ratios to determine predictors of the use of reperfusion therapy in four subgroups of patients categorized according to race and sex: white men, white women, black men, and black women.

RESULTS

Among eligible patients, white men received reperfusion therapy with the highest frequency (59 percent), followed by white women (56 percent), black men (50 percent), and black women (44 percent). After adjustment for differences in demographic and clinical characteristics, white women were as likely as white men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.98 to 1.03). Likewise, black women were as likely as black men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.89 to 1.13). However, black women were significantly less likely to receive reperfusion therapy than white men (prevalence ratio, 0.90; 95 percent confidence interval, 0.82 to 0.98), as were black men (prevalence ratio, 0.85; 95 percent confidence interval, 0.78 to 0.93).

CONCLUSIONS

After adjustment for differences in clinical and demographic characteristics and clinical presentation, differences according to sex in the use of reperfusion therapy are minimal. However, blacks, regardless of sex, are significantly less likely than whites to receive this potentially lifesaving therapy.

Clinical profile and long-term prognosis of women < or = 50 years of age referred for coronary angiography for evaluation of chest pain

A significant lack of information exists regarding risk factors, preventive strategies, diagnostic testing, and treatment of women with coronary artery disease (CAD), especially in the young age group. We studied the clinical profile, angiographic results, and long-term follow-up of 135 women aged < or =50 years referred for coronary angiography because of chest pain. The most prominent risk factor was hyperlipidemia (60%), followed by a family history of coronary disease (44%), systemic hypertension (40%), cigarette smoking (31%), postmenopausal state (23%), and diabetes mellitus (21%). Angiographically significant CAD was demonstrated in 79 of 135 patients (58%), most of whom (61%) had 1-vessel CAD. Women with compared to those without significant CAD had a higher prevalence of hyperlipidemia (71% vs 45%; p = 0.002) and of the post-menopausal state (30% vs 16%; p = 0.028). There was no difference in the incidence of positive noninvasive evaluation (ergometry or thallium scan) before catheterization between women with or without significant coronary lesions. At a follow-up period of 2 to 7 years, 3 women had acute myocardial infarction, all of whom demonstrated coronary lesions on prior angiography. No difference was found regarding the recurrence of chest pain on follow-up between women with or without significant CAD. Mortality and congestive heart failure were observed more frequently in women with CAD (6% vs 0%; p = 0.0516 and 12% vs 2%; p = 0.047, respectively).

Lipid management and control of other coronary risk factors in the postmenopausal woman

This review identifies coronary heart disease (CHD) as the leading cause of mortality among postmenopausal women and highlights the well-documented problem of underrecognition and undertreatment of women who are at risk for or who already have CHD. This undertreatment encompasses both preventive care (i.e., drug treatment for lipid management) and more invasive treatments (e.g., revascularization procedures). Preventive interventions to reduce dyslipidemia and control other coronary risk factors can lessen CHD mortality and morbidity in the postmenopausal woman.

Relation of gender and health insurance to cardiovascular procedure use in persons with progression of chronic renal disease

BACKGROUND

Women often are less likely than men to receive diagnostic and therapeutic invasive procedures for coronary disease.

OBJECTIVE

To examine the relation between gender, health insurance, and access to cardiovascular procedures over time in persons with chronic illness.

RESEARCH DESIGN

Seven-year longitudinal analyses in a cohort from the United States Renal Data System.

SUBJECTS

National random sample of women and men who progressed to end-stage renal disease (ESRD) in 1986 to 1987 and were treated at 303 dialysis facilities (n = 4,987).

MEASURES

Medical history and utilization records, physical examination, and laboratory data.

MAIN OUTCOME MEASURES

Receipt of a coronary catheterization or revascularization procedure before (baseline) and after (follow-up) the development of ESRD and acquisition of Medicare, adjusted for clinical and socioeconomic variables.

RESULTS

At baseline, 5.2% of women and 9.2% of men had undergone a cardiac procedure; the odds of women receiving a procedure were one third lower than for men (adjusted odds ratio 0.66 [95% CI 0.49-0.88]). During follow-up, women were just as likely as men to undergo a procedure (adjusted odds ratio 0.94 [95% CI 0.74-1.20]). Compared with men with baseline private insurance, men and women with other and no insurance had 34% to 81% lower odds of receiving procedures at baseline. Women with private insurance had 42% lower odds of having a procedure at baseline compared with men (adjusted odds ratio 0.58 [95% CI 0.42-0.78]) but had the same odds at follow-up (adjusted odds ratio 1.09 [95% CI 0.82-1.45]). At follow-up, gender differences in procedure use were eliminated for groups with baseline Medicaid or no insurance.

CONCLUSIONS

Overall gender differences in cardiac procedure use were narrowed markedly after progression of a serious illness, the assurance of health insurance, and entry into a comprehensive care system. Gender disparities in procedure use for different baseline insurance groups were largely equalized in follow-up. These findings suggest that provision of insurance with disease-managed care for a chronic disease can provide equalized access to care for women.

Refiguring "race": epidemiology, racialized biology, and biological expressions of race relations

Given growing appreciation of how race/ethnicity is a social, not biological, construct, some epidemiologists are proposing that studies omit data on "race" and instead collect better socioeconomic data. This suggestion, however, ignores a growing body of evidence on how noneconomic as well as economic aspects of racial discrimination are embodied and harm health across the lifecourse. Developing a critical epidemiology of social inequalities in health will, at the very least, require incorporating thoughtful measures of race/ethnicity and social class in epidemiological studies and public health surveillance systems.

The risks of multimedia methods: effects of actor's race and gender on preferences for health states

OBJECTIVE

While the use of multimedia methods in medical education and decision support can facilitate learning, it also has certain hazards. One potential hazard is the inadvertent triggering of racial and gender bias by the appearance of actors or patients in presentations. The authors hypothesized that race and gender affect preferences. To explore this issue they studied the effects of actors' race and gender on preference ratings for health states that include symptoms of schizophrenia.

DESIGN

A convenience sample of patients with schizophrenia, family members of patients, and health professionals was used. Participants were randomly assigned to rate two health states, one portrayed by either a man of mixed race (Hispanic-black) or a white man and the second portrayed by either a white woman or a white man.

MEASUREMENTS

Visual analog scale (VAS) and standard gamble ratings of health state preferences for health states that include symptoms of mild and moderate schizophrenia.

RESULTS

Studies of the effects of the race of the actor (n = 114) revealed that racial mismatch between the actor and the participant affected the participant's preferences for health states. Ratings were lower when racial groups differed (mean difference, 0.098 for visual analog scale ratings and 0.053 lower in standard gamble, P = 0.006 for interactions between the race of the subject and the actor). In studies of the effects of a female actress on ratings (n = 117), we found no evidence of a corresponding interaction between the gender of the actor and the study participant. Rather, an interaction between actor's gender and method of assessment was observed. Standard gamble ratings (difference between means, 0.151), but not visual analog scale ratings (difference, 0.005), were markedly higher when the state was portrayed by the actress (P = 0.003 for interactions between actor's gender and method of preference assessment). Differential effects on standard gamble ratings suggest that an actor's gender may influence the willingness of viewers to gamble to gain health benefits (or risk attitude).

CONCLUSIONS

Educators and researchers considering the use of multimedia methods for decision support need to be aware of the potential for the race and gender of patients or actors to influence preferences for health states and thus, potentially, medical decisions.

Effect of a patient's psychiatric history on physicians' estimation of probability of disease

A questionnaire was mailed to 300 Iowa family physicians to determine the influence of a prior psychiatric history on decision making. The response rate was 77%. Respondents were less likely to believe that a patient had serious illness when presenting with a severe headache or abdominal pain if the patient had a prior history of depression ( P <.05) or prior history of somatic complaints ( P <. 05), compared with a patient with no past history. Respondents were less likely to report that they would order testing for a patient with headache or abdominal pain if the patient had a history of depression ( P <.05, P =.08, respectively) or somatic complaints ( P <.01). Differences in likelihood of ordering tests were not significant after adjusting for differences in estimated probability of disease. We conclude that physicians respond differently to patients with psychiatric illness because of their estimation of pretest probability of disease rather than bias. We conclude that past psychiatric history influences physicians' estimation of disease presence and willingness to order tests.

Stalked by the past: the influence of ethnicity on health

Ethnicity impacts the course of illness and medical treatment. There are enormous ethnic differences in care delivered to patients who are treated for pain. However, in addition to these social forces, there are enormous ethnic differences in physiological response to stimuli as diverse as diet, exposure to agonist infusions, or habitual patterns of response to stressors. The author's clinical research studies on this topic for the last 20 years are reviewed in this article.

The effect of patient race and socio-economic status on physicians' perceptions of patients

Despite its potential influence on quality of care, there has been little research on the way physicians perceptions of and beliefs about patients are affected by patient race or socio-economic status. The lack of research in this area creates a critical gap in our understanding of how patients' demographic characteristics influence encounter characteristics, diagnoses, treatment recommendations, and outcomes. This study uses survey data to examine the degree to which patient race and socio-economic status affected physicians' perceptions of patients during a post-angiogram encounter. A total of 842 patient encounters were sampled, out of which 193 physicians provided data on 618 (73%) of the encounters sampled. The results of analyses of the effect of patient race and SES on physician perceptions of and attitude towards patients, controlling for patient age, sex, race, frailty/sickness, depression, mastery, social assertiveness and physician characteristics, are presented. These results supported the hypothesis that physicians' perceptions of patients were influenced by patients' socio-demographic characteristics. Physicians tended to perceive African-Americans and members of low and middle SES groups more negatively on a number of dimensions than they did Whites and upper SES patients. Patient race was associated with physicians' assessment of patient intelligence, feelings of affiliation toward the patient, and beliefs about patient's likelihood of risk behavior and adherence with medical advice; patient SES was associated with physicians' perceptions of patients' personality, abilities, behavioral tendencies and role demands. Implications are discussed in terms of further studies and potential interventions.

Patient satisfaction with hospital care: effects of demographic and institutional characteristics

BACKGROUND

There are a growing number of efforts to compare the service quality of health care organizations on the basis of patient satisfaction data. Such efforts inevitably raise questions about the fairness of the comparisons. Fair comparisons presumably should not penalize (or reward) health care organizations for factors that influence satisfaction scores but are not within the control of managers or clinicians. On the basis of previous research, these factors might include the demographic characteristics of patients (eg, age) and the institutional characteristics (eg, size) of the health care organizations where care was received.

OBJECTIVES

The goal of this study was to examine the extent to which a patient's satisfaction scores are related to both his/her demographic characteristics and the institutional characteristics of the health care organization where care was received.

METHODS

We conducted an analysis of secondary data from the Veterans Health Administration (VHA), US Department of Veterans Affairs. The database contained patient responses to self-administered satisfaction questionnaires and information about demographic characteristics. Additional data from VHA were obtained regarding the institutional characteristics of the hospitals where patients received their care.

RESULTS

Among demographic characteristics, age, health status, and race consistently had a statistically significant effect on satisfaction scores. Among the institutional characteristics, hospital size consistently had a significant effect on patient satisfaction scores.

CONCLUSIONS

Study results can be interpreted as justifying the need to adjust patient satisfaction scores for differences in patient population among health care organizations. However, from a policy perspective, such adjustments may ultimately create a disincentive for health care organizations to customize their care.

The excess burden of breast carcinoma in minority and medically underserved communities: application, research, and redressing institutional racism

BACKGROUND

In 1998, the American Cancer Society, the National Cancer Institute, and the Centers for Disease Control and Prevention reported an overall downward trend in cancer incidence and mortality between 1990 and 1995 for all cancers combined. Many minority and medically underserved populations, however, did not share equally in these improvements.

METHODS

A review of surveillance and other reports and recent literature on disparities in cancer incidence and mortality in minority and medically underserved communities was conducted 1) to ascertain the extent to which these communities bear an excess cancer burden, and 2) to explore the macrosocietal and microinstitutional barriers to equitable benefits in cancer health care delivery.

RESULTS

Tragic disparities in cancer incidence and mortality in minority and medically underserved communities continue to be inadequately addressed. Overall improvements in U.S. cancer incidence and mortality rates are not shared equally by all segments of our society. While numerous individual and cultural barriers to optimal cancer control and care exist in minority and medically underserved communities, a major factor precluding these populations from sharing equally in advances in cancer research is prevailing societal and institutional racism.

CONCLUSIONS

Immediate and equitable application of existing cancer control interventions and quality treatment options will significantly decrease cancer incidence and mortality. Enhanced surveillance efforts and a greater investment in targeted cancer research in those communities with the greatest disparities must be employed immediately if we are to achieve the goal of the president of the United States of eliminating racial and ethnic disparities in cancer and other diseases by 2010. Unless we acknowledge and redress institutionalized racism, the miscarriage of health justice will be perpetuated while celebrated advances in cancer research leading to declining incidence and mortality rates continue to evade our nation's minority and medically underserved communities.

Socioeconomic factors and breast carcinoma in multicultural women

Breast carcinoma is the most common cancer in women in the U.S. and the second leading cause of cancer death in women. Furthermore, there are racial differences in breast carcinoma incidence, mortality, and survival rates. Social and economic factors within racial/ethnic groups are being examined as risk factors not only for breast carcinoma mortality and survival but also as determinants of the rate of incidence. Social and economic factors have been associated in the literature predominantly with cancer mortality and survival. When socioeconomic status (SES) is considered, certain studies suggest that racial disparities in breast carcinoma are smaller than when social and economic factors are examined alone, but these disparities still persist. Sources of data for this discussion include the National Cancer Institute (NCI) (the Surveillance, Epidemiology, and End Results [SEER] program, a group of population-based cancer registries that cover up to 14% of the U.S. population. SEER reports cancer incidence, mortality, and survival rates), the U.S. Bureau of the Census, the National Center for Health Statistics (NCHS), and numerous articles from the scientific literature. Socioeconomic factors or SES can be considered "cross-cutting risk factors" (i.e., they can be related to the risk of developing breast carcinoma [rate of incidence] as well as to the risk of dying [mortality] from this disease). They also are the risk factors that "cut across" racial and ethnic populations. Socioeconomic factors are related to breast carcinoma mortality and survival rates in multicultural women. Racial disparities in breast carcinoma mortality and survival rates can be explained partially by stage distribution at the time of diagnosis, which may be related to SES. For example, African-American women present with more advanced stage distributions for breast carcinoma than white women. Similarly, women of lower SES present with higher stage disease than women of upper SES who present with more localized breast carcinoma. The lack of data regarding the SES of cancer patients limits our understanding of the contributions of SES to cancer incidence and mortality rates. SES appears to be related to breast carcinoma incidence, mortality, and survival rates. Breast carcinoma mortality is higher in women of lower SES. Additional research on SES, race, culture, and the relation of these factors to cancer incidence rate is needed.

Racial differences in the utilization of oral anticoagulant therapy in heart failure: a study of elderly hospitalized patients

To assess racial differences in the use of oral anticoagulant therapy for patients with heart failure, we conducted a cohort study of 30 hospitals in northeast Ohio. For 12,911 Medicare enrollees consecutively admitted in 1992 through 1994 with heart failure, crude and adjusted odds of being on oral anticoagulation were determined. The crude and adjusted odds of being African Americans on oral anticoagulant therapy relative to whites were 0.57 (95% confidence interval 0.47-0.69) and 0.55 (95% confidence interval 0. 45-0.67), respectively. African-Americans with heart failure were much less likely than whites to receive oral anticoagulant therapy, even after adjusting for other variables associated with anticoagulant use.

Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model

This article develops a conceptual model of cultural competency's potential to reduce racial and ethnic health disparities, using the cultural competency and disparities literature to lay the foundation for the model and inform assessments of its validity. The authors identify nine major cultural competency techniques: interpreter services, recruitment and retention policies, training, coordinating with traditional healers, use of community health workers, culturally competent health promotion, including family/community members, immersion into another culture, and administrative and organizational accommodations. The conceptual model shows how these techniques could theoretically improve the ability of health systems and their clinicians to deliver appropriate services to diverse populations, thereby improving outcomes and reducing disparities. The authors conclude that while there is substantial research evidence to suggest that cultural competency should in fact work, health systems have little evidence about which cultural competency techniques are effective and less evidence on when and how to implement them properly.

Variations in risk-adjusted cesarean delivery rates according to race and health insurance

OBJECTIVE

To assess the association between race and insurance and Cesarean delivery rates after adjusting for clinical risk factors that increase the likelihood of cesarean delivery.

DESIGN

Retrospective cohort study in 21 hospitals in northeast Ohio.

SUBJECTS

25,697 women without prior cesarean deliveries admitted for labor and delivery January 1993 through June 1995.

METHODS

Demographic and clinical data were abstracted from patients' medical records. The risk of cesarean delivery was adjusted for 39 maternal and neonatal risk factors that were included in a previously developed risk-adjustment model using nested logistic regression analysis.

MAIN OUTCOME MEASURES

Odds ratios for cesarean delivery in nonwhite patients relative to whites and for patients with government insurance or who were uninsured relative to patients with commercial insurance.

RESULTS

The overall rate of cesarean delivery was similar in white and nonwhite patients (15.8% and 16.1%, respectively), but rates varied (P < 0.001) according to insurance (17.0%, 14.2%, 10.7% in patients with commercial insurance, government insurance, and without insurance, respectively). However, after adjusting for clinical factors, the adjusted odds ratio (OR) of cesarean delivery was higher in nonwhite patients (OR = 1.34; 95% CI: 1.14-1.57; P < 0.001), but similar for patients with government insurance (OR = 1.01; 95% CI: 0.90-1.14; P = 0.84) and lower for uninsured patients (OR = 0.65; 95% CI, 0.41, 1.03; P = 0.067), albeit not statistically significant. In analyses stratified according to quintiles of predicted risk of cesarean delivery, racial differences were largely limited to patients in the lower risk quintiles. However, differences in odds ratios for uninsured patients were seen across the risk quintiles, although odds ratios were not statistically significant.

CONCLUSION

After adjusting for clinical factors, race and insurance status may independently influence the use of cesarean delivery. The higher rates in nonwhites and lower rates in the uninsured may reflect differences in patient preferences or expectations, differences in physician practice, or unmeasured risk factors. The lower odds of cesarean delivery in uninsured women, particularly women at high risk, may raise the issue of underutilization of services and warrants further study.

Legal implications of discrimination in medical practice

Recent medical studies have indicated that medical professionals discriminate in their treatment practices on the basis of race and gender. Among the many concerns stemming from this realization are questions about the possibility of legal actions and the availability of individual compensation for the denial of equal care. By meeting legal evidentiary standards, the recent statistical data pointing to discriminatory trends have created the potential for legal recourse through Title VI of the Civil Rights Act which prohibits recipients of federal funding from treating people differently on the basis of race or national origin.

A novel united network for organ sharing region kidney allocation plan improves transplant access for minority candidates

BACKGROUND

We report the consequences of a novel kidney allocation system on access of non-Caucasians (NC) to kidney transplantation. This new plan has provided a balance of allocation determinants between time waiting, HLA match, and geography (population density between donor and recipient center).

METHODS

Three sequential systems of regional allocation were analyzed: period I (September 1994 to September 1996), period II (September 1996 to November 1997), and period III (December 1997 to March 1 1999). Periods II and III are reflective of the new allocation plan.

RESULTS

During periods II and III, the NC rate of kidney transplantation increased closer to the NC proportion on the wait list, comparatively exceeding the national UNOS data. There was no statistical difference in regional mean wait time between Caucasian and NC. Improvements in access to transplantation for NCs between period I and periods II and III appear to be related to changes in geographic allocation weight from local unit to population density points, to the inclusion of the entire region in the plan, and to the deletion of intermediate degrees of B/DR mismatching in the revised plan. Despite the increased proportion of NCs on the wait list from period I to period III, the percentage difference between the proportion of NCs waiting on the list and the proportion NCs receiving a transplant fell from 7.8% to 4.9%.

CONCLUSIONS

These data demonstrate that this new allocation plan was associated with improved access of minority candidates to transplantation. The broadening of geographic allocation and the alteration of HLA points appear to permit a more favorable opportunity for renal transplantation to NC candidates. selection, compared to the UNOS formula. In this report, we analyze the consequences of the Region 1 allocation system on the access of non-Caucasian (NC) candidates to cadaver donor kidney transplantation.

Part II. Educating for diversity: a decade of experience (1989-1999)

In response to tensions created by a racial misunderstanding, the authors developed a course for first year medical students entitled Race and Gender in Medicine. The course, presented in a seminar format, enables the participants to discuss openly their concerns about diversity and its impact on their institution and the medical enterprise. Physician speakers describe their experiences with gender bias, racism, and other discriminatory practices and then present strategies they used to overcome these obstacles in their career path. Given the increasing heterogeneity of the population, the authors advocate integrating a course such as this one into the curriculum that will help prepare students to practice humane medicine in the multiracial, multiethnic, and multicultural society of the 21st century.

The effect of patients' preferences on racial differences in access to renal transplantation

BACKGROUND

In the United States, black patients undergo renal transplantation less often than white patients, but few studies have directly assessed the association between race and patients' preferences with respect to transplantation.

METHODS

To assess preferences with respect to transplantation and experiences with medical care, we interviewed 1392 (82.9 percent) of 1679 eligible patients with end-stage renal disease (age range, 18 to 54 years) approximately 10 months after they had begun maintenance treatment with dialysis. Participants were selected from a stratified random sample of patients undergoing dialysis in four regions of the United States (Alabama, southern California, Michigan, and the mid-Atlantic region of Maryland, Virginia, and the District of Columbia) in 1996 and 1997. Patients were followed until March 1999.

RESULTS

The interviews were conducted with 384 black women, 354 white women, 337 black men, and 317 white men. Black patients were less likely than white patients to want a transplant (76.3 percent of black women reported such a preference, vs. 79.3 percent of white women, and 80.7 percent of black men vs. 85.5 percent of white men), and they were less likely to be very certain about this preference (58.3 percent vs. 65.3 percent and 64.1 percent vs. 75.7 percent, respectively; P<0.01 for each comparison with both sexes combined). However, much larger differences were evident in rates of referral for evaluation at a transplantation center (50.4 percent for black women vs. 70.5 percent for white women, and 53.9 percent for black men vs. 76.2 percent for white men; P<0.001 for each comparison) and placement on a waiting list or transplantation within 18 months after the start of dialysis therapy (31.3 percent for black women vs. 56.5 percent for white women, and 35.3 percent for black men vs. 60.6 percent for white men; P<0.001). These racial differences remained significant after adjustment for patients' preferences and expectations about transplantation, sociodemographic characteristics, the type of dialysis facility, perceptions of care, health status, the cause of renal failure, and the presence or absence of coexisting illnesses.

CONCLUSIONS

In the United States, the preferences and expectations with respect to renal transplantation among patients with end-stage renal disease differ according to race. These differences, however, explain only a small fraction of the substantial racial differences in access to transplantation. Physicians should ensure that black patients who desire renal transplantation are fully informed about it and are referred for evaluation.

Influence of patient education on profiles of physician practices

BACKGROUND

Few data are available about the effect of patient socioeconomic status on profiles of physician practices.

OBJECTIVE

To determine the ways in which adjustment for patients' level of education (as a measure of socioeconomic status) changes profiles of physician practices.

DESIGN

Cross-sectional survey of patients in physician practices.

SETTING

Managed care organization in western New York State.

PARTICIPANTS

A random sample of 100 primary care physicians and 50 consecutive patients seen by each physician.

MEASUREMENTS

Ranks of physicians for patient physical and mental health (Short Form 12-Item Health Survey) and satisfaction (Patient Satisfaction Questionnaire), adjusted for patient age, sex, morbidity, and education.

RESULTS

Physicians whose patients had a lower mean level of education had significantly better ranks for patient physical and mental health status after adjustment for patients' level of education level than they did before adjustment (P < 0.001); this result was not seen for patient satisfaction. After adjustment for patients' level of education, each 1-year decrease in mean educational level was associated with a rank that improved by 8.1 (95% CI, 6.6 to 9.6) for patient physical health status and by 4.9 (CI, 3.9 to 5.9) for patient mental health status. Adjustment for education had similar effects for practices with more educated patients and those with less educated patients.

CONCLUSIONS

Profiles of physician practices that base ratings of physician performance on patients' physical and mental health status are substantially affected by patients' level of education. However, these results do not suggest that physicians who care for less educated patients provide worse care. Physician profiling should account for differences in patients' level of education.

Prevalence of coronary artery disease, ischemic stroke, peripheral arterial disease, and coronary revascularization in older African-Americans, Asians, Hispanics, whites, men, and women

The prevalence of coronary artery disease and of peripheral arterial disease was similar in older African-Americans, Asians, Hispanics, and whites, and the prevalence of ischemic stroke was lower in older whites than in older African-Americans and Hispanics. The prevalence of coronary revascularization in older persons with coronary artery disease was lower in African-Americans than in whites and Hispanics and was lower in women than in men.

Racial differences in the treatment of early-stage lung cancer

BACKGROUND

If discovered at an early stage, non-small-cell lung cancer is potentially curable by surgical resection. However, two disparities have been noted between black patients and white patients with this disease. Blacks are less likely to receive surgical treatment than whites, and they are likely to die sooner than whites. We undertook a population-based study to estimate the disparity in the rates of surgical treatment and to evaluate the extent to which this disparity is associated with differences in overall survival.

METHODS

We studied all black patients and white patients 65 years of age or older who were given a diagnosis of resectable non-small-cell lung cancer (stage I or II) between 1985 and 1993 and who resided in 1 of the 10 study areas of the Surveillance, Epidemiology, and End Results (SEER) program (10,984 patients). Data on the diagnosis, stage of disease, treatment, and demographic characteristics of the patients were obtained from the SEER data base. Information on coexisting illnesses, type of Medicare coverage, and survival was obtained from linked Medicare inpatient-discharge records.

RESULTS

The rate of surgery was 12.7 percentage points lower for black patients than for white patients (64.0 percent vs. 76.7 percent, P<0.001), and the five-year survival rate was also lower for blacks (26.4 percent vs. 34.1 percent, P<0.001). However, among the patients undergoing surgery, survival was similar for the two racial groups, as it was among those who did not undergo surgery. Furthermore, analyses in which adjustments were made for factors that are predictive of either candidacy for surgery or survival did not alter the influence of race on these outcomes.

CONCLUSIONS

Our analyses suggest that the lower survival rate among black patients with early-stage, non-small-cell lung cancer, as compared with white patients, is largely explained by the lower rate of surgical treatment among blacks. Efforts to increase the rate of surgical treatment for black patients appear to be a promising way of improving survival in this group.

Diagnosing suffering: a perspective

The alleviation of suffering is crucial in all of medicine, especially in the care of the dying. Suffering cannot be treated unless it is recognized and diagnosed. Suffering involves some symptom or process that threatens the patient because of fear, the meaning of the symptom, and concerns about the future. The meanings and the fear are personal and individual, so that even if two patients have the same symptoms, their suffering would be different. The complex techniques and methods that physicians usually use to make a diagnosis, however, are aimed at the body rather than the person. The diagnosis of suffering is therefore often missed, even in severe illness and even when it stares physicians in the face. A high index of suspicion must be maintained in the presence of serious disease, and patients must be directly questioned. Concerns over the discomfort of listening to patients' severe distress are usually more than offset by the gratification that follows the intervention. Often, questioning and attentive listening, which take little time, are in themselves ameliorative. The information on which the assessment of suffering is based is subjective; this may pose difficulties for physicians, who tend to value objective findings more highly and see a conflict between the two kinds of information. Recent advances in understanding how physicians increase the utility of information and make inferences allow one to reliably use the subjective information on which the diagnosis and treatment of suffering depend. Knowing patients as individual persons well enough to understand the origin of their suffering and ultimately its best treatment requires methods of empathic attentiveness and nondiscursive thinking that can be learned and taught. The relief of suffering depends on physicians acquiring these skills.