The state of research on racial/ethnic discrimination in the receipt of health care

Trends and Disparities in Postpartum Sterilization after Cesarean Section, 2000 through 2008

PURPOSE

Tubal sterilization patterns are influenced by factors including patient race, ethnicity, level of education, method of payment, and hospital size and affiliation. However, less is known about how these factors influence tubal sterilizations performed as secondary procedures after cesarean sections (C-sections). Thus, this study examines variations in the prevalence of postpartum tubal sterilizations after C-sections from 2000 to 2008.

METHODS

We used data from the National Hospital Discharge Survey to estimate odds ratios for patient-level (race, marital status, age) and system-level (hospital size, type, region) factors on the likelihood of receiving tubal sterilization after C-section.

RESULTS

A disproportionate share of postpartum tubal sterilizations after C-section was covered by Medicaid. The likelihood of undergoing sterilization was increased for Black women, women of older age, and non-single women. Additionally, they were increased in proprietary and government hospitals, smaller hospital settings, and the Southern United States.

CONCLUSIONS

Our findings indicate that Black women and those with Medicaid coverage in particular were substantially more likely to undergo postpartum tubal sterilization after C-section. We also found that hospital characteristics and region were significant predictors. This adds to the growing body of evidence that suggests that tubal sterilization may be a disparity issue patterned by multiple factors and calls for greater understanding of the role of patient-, provider-, and system-level characteristics on such outcomes.

Perceptions of racism in healthcare among patients with systemic lupus erythematosus: a cross-sectional study

Background

Racial disparities in the clinical outcomes of systemic lupus erythematosus (SLE) exist. Perceived racial discrimination may contribute to disparities in health.

Objectives

To determine if perceived racism in healthcare differs by race among patients with SLE and to evaluate its contribution to racial disparities in SLE-related outcomes.

Methods

163 African–American (AA) and 180 white (WH) patients with SLE were enrolled. Structured interviews and chart reviews were done to determine perceptions of racism, SLE-related outcomes (Systemic Lupus International Collaborating Clinics (SLICC) Damage Index, SLE Disease Activity, Center for Epidemiologic Studies-Depression (CES-D)), and other variables that may affect perceptions of racism. Serial hierarchical multivariable logistic regression models were conducted. Race-stratified analyses were also performed.

Results

56.0% of AA patients compared with 32.8% of WH patients had high perceptions of discrimination in healthcare (p<0.001). This difference remained (OR 4.75 (95% CI 2.41 to 8.68)) after adjustment for background, identity and healthcare experiences. Female gender (p=0.012) and lower trust in physicians (p<0.001) were also associated with high perceived racism. The odds of having greater disease damage (SLICC damage index ≥2) were higher in AA patients than in WH patients (crude OR 1.55 (95% CI 1.01 to 2.38)). The odds of having moderate to severe depression (CES-D ≥17) were also higher in AA patients than in WH patients (crude OR 1.94 (95% CI 1.26 to 2.98)). When adjusted for sociodemographic and clinical characteristics, racial disparities in disease damage and depression were no longer significant. Among AA patients, higher perceived racism was associated with having moderate to severe depression (adjusted OR 1.23 (95% CI 1.05 to 1.43)) even after adjusting for sociodemographic and clinical variables.

Conclusions

Perceptions of racism in healthcare were more common in AA patients than in WH patients with SLE and were associated with depression. Interventions aimed at modifiable factors (eg, trust in providers) may reduce higher perceptions of race-based discrimination in SLE.

Perceived discrimination in U.S. healthcare: Charting the effects of key social characteristics within and across racial groups

This article employs an original empirical analysis to contribute to scientific understandings of the relationship between social characteristics and perceptions of discrimination in healthcare encounters within and across racial categories in the U.S. Our analysis focuses on a diverse sample of 43,020 adults aged 18 to 85 drawn from the California Health Interview Survey (CHIS). We use a series of weighted descriptive statistics and logistic regression models to parse out factors associated with perceived discrimination and chart how they vary by race and ethnicity. Members of racial minorities were more likely to report perceptions of discrimination, and while the effect was somewhat mitigated by introducing patient and health-care system factors into our models, the race effects remained both statistically significant and of substantial magnitude (particularly for African Americans and Native Americans). Poor self-reported health and communication difficulties in the clinical encounter were associated with increased perceptions of discrimination across all groups. Further, among non-whites, increased education was associated with increased perceptions of discrimination net of other factors. These findings suggest efforts to reduce disparities in medical care should continue to focus on expanding the depth and quality of patient–provider interactions for disadvantaged racial groups, while also being attentive to other factors that affect perceived racial discrimination in healthcare encounters within and across racial groups.

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Race shapes perceived discrimination net of other factors.

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Some of the race effect can be accounted for by individual and system level factors.

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Interactions with providers have a powerful effect on perceptions of discrimination.

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The effect of factors such as education varies between racial groups.

Reports of insurance-based discrimination in health care and its association with access to care

OBJECTIVES

We examined reports of insurance-based discrimination and its association with insurance type and access to care in the early years of the Patient Protection and Affordable Care Act.

METHODS

We used data from the 2013 Minnesota Health Access Survey to identify 4123 Minnesota adults aged 18 to 64 years who reported about their experiences of insurance-based discrimination. We modeled the association between discrimination and insurance type and predicted odds of having reduced access to care among those reporting discrimination, controlling for sociodemographic factors. Data were weighted to represent the state's population.

RESULTS

Reports of insurance-based discrimination were higher among uninsured (25%) and publicly insured (21%) adults than among privately insured adults (3%), which held in the regression analysis. Those reporting discrimination had higher odds of lacking a usual source of care, lacking confidence in getting care, forgoing care because of cost, and experiencing provider-level barriers than those who did not.

CONCLUSIONS

Further research and policy interventions are needed to address insurance-based discrimination in health care settings.

Ethnic disparities in trauma mortality outcomes

BACKGROUND

Ethnic disparities in trauma mortality outcomes have been demonstrated in the United States according to the US National Trauma Data Bank. The aim of this study was to determine the effect of race/ethnicity on trauma mortality in Singapore.

METHODS

This was a retrospective review of patients aged 18-64 years with an injury severity score (ISS) ≥ 9 in the Trauma Registry of Tan Tock Seng Hospital, a 1,300-bed trauma center in Singapore, from 2006 to 2010. Chinese, Malay, and Indian patients were compared with patients of other ethnic groups. Multiple logistic regression analyses determined differences in survival rates after adjusting for demographics, anatomic and physiologic ISS and revised trauma score, mechanism or type of injury.

RESULTS

A total of 4,186 patients (66.4 % of the database) met the inclusion criteria. Most patients were male (76.3 %) and young (mean age 40 years). Using Chinese as the reference group, we found no statistically significant differences in unadjusted or adjusted mortality rates among the ethnic groups. Independent predictors of mortality included age [odds ratio (OR) 1.05, 95 % confidence interval (CI) 1.03-1.06, p < 0.0001], presence of severe head injury (OR 1.75, 95 % CI 1.13-2.69, p = 0.012), and increasing ISS (p < 0.0001).

CONCLUSIONS

Ethnicity is not an independent predictor of trauma mortality outcomes in the Singapore population. Our findings contrast with those from the United States, where race/ethnicity (Black and Hispanic) remains a strong independent risk factor for trauma mortality. This study attests to the success of the Singapore health care/trauma system in delivering the same quality of care regardless of ethnicity.

Does the availability of a South Asian language in practices improve reports of doctor-patient communication from South Asian patients? Cross sectional analysis of a national patient survey in English general practices

BACKGROUND

Ethnic minorities report poorer evaluations of primary health care compared to White British patients. Emerging evidence suggests that when a doctor and patient share ethnicity and/or language this is associated with more positive reports of patient experience. Whether this is true for adults in English general practices remains to be explored.

METHODS

We analysed data from the 2010/2011 English General Practice Patient Survey, which were linked to data from the NHS Choices website to identify languages which were available at the practice. Our analysis was restricted to single-handed practices and included 190,582 patients across 1,068 practices. Including only single-handed practices enabled us to attribute, more accurately, reported patient experience to the languages that were listed as being available. We also carried out sensitivity analyses in multi-doctor practices. We created a composite score on a 0-100 scale from seven survey items assessing doctor-patient communication. Mixed-effect linear regression models were used to examine how differences in reported experience of doctor communication between patients of different self-reported ethnicities varied according to whether a South Asian language concordant with their ethnicity was available in their practice. Models were adjusted for patient characteristics and a random effect for practice.

RESULTS

Availability of a concordant language had the largest effect on communication ratings for Bangladeshis and the least for Indian respondents (p < 0.01). Bangladeshi, Pakistani and Indian respondents on average reported poorer communication than White British respondents [-2.9 (95%CI -4.2, -1.6), -1.9 (95%CI -2.6, -1.2) and -1.9 (95%CI -2.5, -1.4), respectively]. However, in practices where a concordant language was offered, the experience reported by Pakistani patients was not substantially worse than that reported by White British patients (-0.2, 95%CI -1.5,+1.0), and in the case of Bangladeshi patients was potentially much better (+4.5, 95%CI -1.0,+10.1). This contrasts with a worse experience reported among Bangladeshi (-3.3, 95%CI -4.6, -2.0) and Pakistani (-2.7, 95%CI -3.6, -1.9) respondents when a concordant language was not offered.

CONCLUSIONS

Substantial differences in reported patient experience exist between ethnic groups. Our results suggest that patient experience among Bangladeshis and Pakistanis is improved where the practice offers a language that is concordant with the patient's ethnicity.

"Respect the way I need to communicate with you": Healthcare experiences of adults on the autism spectrum

Our objective was to obtain an in-depth understanding of autistic adults' experiences with healthcare and their recommendations for improving care. Our academic-community partnership used a community-based participatory research approach to conduct semi-structured, open-ended interviews with 39 autistic adults and 16 people who had experience supporting autistic adults in healthcare settings. Participants identified patient-level, autism-related factors that impact healthcare interactions, including verbal communication skills, sensory sensitivities, challenges with body awareness, slow processing speed, atypical non-verbal communication, and challenges with organization. However, the success of healthcare interactions largely depended on the interplay between patient- and provider-level factors, as well as the larger context in which patients were receiving care. Provider-level factors included providers' knowledge about autism in adults, incorrect assumptions about individual patients, willingness to allow written communication, use of accessible language, openness to providing other accommodations, and skill in appropriately incorporating supporters. System-level factors included the availability of supporters, complexity of the healthcare system, accessibility of healthcare facilities, and stigma about autism. Further efforts are needed to empower patients, adequately train providers, increase the accessibility of the healthcare system, and decrease discrimination.

Propensity score matching to measure the effect of survey mode on reports of racial and ethnic discrimination in health care

OBJECTIVE

To examine the effect of survey mode (mail vs. telephone) on the likelihood of reporting health care-related discrimination based on race, ethnicity, or nationality.

METHODS

We use data from a mixed-mode, mail and telephone survey of public health care program enrollees (N=2807), including Somali, Hmong, African American, American Indian, and Latino populations. Self-reported discrimination was measured as the experience of unfair treatment by health care providers due to race, ethnicity, or nationality. We use propensity score matching to create exchangeable groups of phone and mail respondents based on the probability of completing the survey by phone.

RESULTS

Overall, 33.1% of respondents reported having experienced discrimination in health care, but only 23.6% of telephone respondents reported discrimination compared with 36.8% of mail respondents. After matching phone and mail respondents based on probability of responding by telephone, all observable significant differences between respondents that were brought about by differential self-selection into mode were erased, allowing us to estimate the effect of survey mode on report of discrimination. Even after matching, the mode effect remains, where report of health care discrimination for telephone respondents would have been 12.6 percentage points higher had they responded by mail (22.6% vs. 35.2%).

CONCLUSIONS

Survey mode has a significant effect on report of discrimination. Respondents may be more willing to disclose experiences of discrimination in a mail survey than to a telephone interviewer. Findings have substantial policy and clinical significance as variation in report of discrimination based on mode may lead to underestimation of the extent of the problem.

Effects of ethnic attributes on the quality of family planning services in Lima, Peru: a randomized crossover trial

Most studies reporting ethnic disparities in the quality of healthcare come from developed countries and rely on observational methods. We conducted the first experimental study to evaluate whether health providers in Peru provide differential quality of care for family planning services, based on the indigenous or mestizo (mixed ethnoracial ancestry) profile of the patient. In a crossover randomized controlled trial conducted in 2012, a sample of 351 out of the 408 public health establishments in Metropolitan Lima, Peru were randomly assigned to receive unannounced simulated patients enacting indigenous and mestizo profiles (sequence-1) or mestizo and then indigenous profiles (sequence-2), with a five week wash-out period. Both ethnic profiles used the same scripted scenario for seeking contraceptive advice but had distinctive cultural attributes such as clothing, styling of hair, make-up, accessories, posture and patterns of movement and speech. Our primary outcome measure of quality of care is the proportion of technical tasks performed by providers, as established by Peruvian family planning clinical guidelines. Providers and data analysts were kept blinded to the allocation. We found a non-significant mean difference of -0.7% (p = 0.23) between ethnic profiles in the percentage of technical tasks performed by providers. However we report large deficiencies in the compliance with quality standards of care for both profiles. Differential provider behaviour based on the patient's ethnic profiles compared in the study did not contribute to deficiencies in family planning outcomes observed. The study highlights the need to explore other determinants for poor compliance with quality standards, including demand and supply side factors, and calls for interventions to improve the quality of care for family planning services in Metropolitan Lima.

Race, ethnicity, and socioeconomic status in research on child health

An extensive literature documents the existence of pervasive and persistent child health, development, and health care disparities by race, ethnicity, and socioeconomic status (SES). Disparities experienced during childhood can result in a wide variety of health and health care outcomes, including adult morbidity and mortality, indicating that it is crucial to examine the influence of disparities across the life course. Studies often collect data on the race, ethnicity, and SES of research participants to be used as covariates or explanatory factors. In the past, these variables have often been assumed to exert their effects through individual or genetically determined biologic mechanisms. However, it is now widely accepted that these variables have important social dimensions that influence health. SES, a multidimensional construct, interacts with and confounds analyses of race and ethnicity. Because SES, race, and ethnicity are often difficult to measure accurately, leading to the potential for misattribution of causality, thoughtful consideration should be given to appropriate measurement, analysis, and interpretation of such factors. Scientists who study child and adolescent health and development should understand the multiple measures used to assess race, ethnicity, and SES, including their validity and shortcomings and potential confounding of race and ethnicity with SES. The American Academy of Pediatrics (AAP) recommends that research on eliminating health and health care disparities related to race, ethnicity, and SES be a priority. Data on race, ethnicity, and SES should be collected in research on child health to improve their definitions and increase understanding of how these factors and their complex interrelationships affect child health. Furthermore, the AAP believes that researchers should consider both biological and social mechanisms of action of race, ethnicity, and SES as they relate to the aims and hypothesis of the specific area of investigation. It is important to measure these variables, but it is not sufficient to use these variables alone as explanatory for differences in disease, morbidity, and outcomes without attention to the social and biologic influences they have on health throughout the life course. The AAP recommends more research, both in the United States and internationally, on measures of race, ethnicity, and SES and how these complex constructs affect health care and health outcomes throughout the life course.

Promoting a new research agenda: health disparities research at the intersection of disability, race, and ethnicity

BACKGROUND

Differences in access to and receipt of health care have been extensively documented across racial and ethnic groups. Similarly, a growing body of research has documented disparities between people with and without disabilities in obtaining needed health care. However, our understanding of the intersection of disability with race and ethnicity in health care is very limited.

OBJECTIVES

The purpose of this supplement is to begin to bridge the gap between research on racial and ethnic health disparities and research on disability-related health disparities.

RESULTS

The papers in this supplement examine evidence of racial and ethnic disparities within various populations of people with disabilities, and explore unique issues at the intersection of disability, race, and ethnicity.

CONCLUSIONS

The studies in this issue provide a starting point, and are intended to serve as an impetus for building a more robust literature on health care issues impacting the expanding segment of United States population that both experience disability and belong to racial and ethnic groups other than non-Hispanic white.

Perceived discrimination in health care is associated with a greater burden of pain in sickle cell disease

CONTEXT

Perceived discriminatory experiences in society have been associated with a higher burden of pain among some minority patient populations.

OBJECTIVES

To describe the extent to which patients with sickle cell disease (SCD) perceive discrimination from health care providers and to examine the association of these experiences with the burden of chronic SCD pain.

METHODS

Cross-sectional analysis of data collected at baseline of a prospective cohort study of SCD patient experiences of care (n = 291). Perceived race-based and disease-based discrimination from health care providers were measured using subscales adapted from the Interpersonal Processes of Care Survey. Discrimination scores were examined for their association with patient characteristics and measures of pain burden using descriptive, bivariate, and multivariate analytic techniques.

RESULTS

Respondents reported a greater burden of race-based discrimination from health care providers than has been previously reported by African Americans, and they reported a greater amount of disease-based vs. race-based discrimination. Age and having difficulty persuading providers about pain were the only patient characteristics independently associated with race-based discrimination, whereas older age, greater emergency room utilization, having difficulty persuading providers about pain, daily chronic pain, fewer good days during a week, and a higher severity of pain on their good days were independently associated with greater disease-based discrimination.

CONCLUSION

Perceived disease-based, but not race-based, discrimination was found to be associated with a greater range of self-reported pain among patients with SCD. If causal, this finding could signal an important new approach to mitigating the burden of pain experienced by persons with SCD.

Discrimination and Health Inequities

In 1999, only 20 studies in the public health literature employed instruments to measure self-reported experiences of discrimination. Fifteen years later, the number of empirical investigations on discrimination and health easily exceeds 500, with these studies increasingly global in scope and focused on major types of discrimination variously involving race/ethnicity, indigenous status, immigrant status, gender, sexuality, disability, and age, separately and in combination. And yet, as I also document, even as the number of investigations has dramatically expanded, the scope remains narrow: studies remain focused primarily on interpersonal discrimination, and scant research investigates the health impacts of structural discrimination, a gap consonant with the limited epidemiologic research on political systems and population health. Accordingly, to help advance the state of the field, this updated review article: ( a) briefly reviews definitions of discrimination, illustrated with examples from the United States; ( b) discusses theoretical insights useful for conceptualizing how discrimination can become embodied and produce health inequities, including via distortion of scientific knowledge; ( c) concisely summarizes extant evidence—both robust and inconsistent—linking discrimination and health; and ( d) addresses several key methodological controversies and challenges, including the need for careful attention to domains, pathways, level, and spatiotemporal scale, in historical context.

Association between race and age in survival after trauma

IMPORTANCE

Racial disparities in survival after trauma are well described for patients younger than 65 years. Similar information among older patients is lacking because existing trauma databases do not include important patient comorbidity information.

OBJECTIVE

To determine whether racial disparities in trauma survival persist in patients 65 years or older.

DESIGN, SETTING, AND PARTICIPANTS

Trauma patients were identified from the Nationwide Inpatient Sample (January 1, 2003, through December 30, 2010) using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Injury severity was ascertained by applying the Trauma Mortality Prediction Model, and patient comorbidities were quantified using the Charlson Comorbidity Index.

MAIN OUTCOMES AND MEASURES

In-hospital mortality after trauma for blacks vs whites for younger (16-64 years of age) and older (≥65 years of age) patients was compared using 3 different statistical methods: univariable logistic regression, multivariable logistic regression with and without clustering for hospital effects, and coarsened exact matching. Model covariates included age, sex, insurance status, type and intent of injury, injury severity, head injury severity, and Charlson Comorbidity Index.

RESULTS

A total of 1,073,195 patients were included (502,167 patients 16-64 years of age and 571,028 patients ≥65 years of age). Most older patients were white (547,325 [95.8%]), female (406 158 [71.1%]), and insured (567,361 [99.4%]) and had Charlson Comorbidity Index scores of 1 or higher (323,741 [56.7%]). The unadjusted odds ratios (ORs) for death in blacks vs whites were 1.35 (95% CI, 1.28-1.42) for patients 16 to 64 years of age and 1.00 (95% CI, 0.93-1.08) for patients 65 years or older. After risk adjustment, racial disparities in survival persisted in the younger black group (OR, 1.21; 95% CI, 1.13-1.30) but were reversed in the older group (OR, 0.83; 95% CI, 0.76-0.90). This finding was consistent across all 3 statistical methods.

CONCLUSIONS AND RELEVANCE

Different racial disparities in survival after trauma exist between white and black patients depending on their age group. Although younger white patients have better outcomes after trauma than younger black patients, older black patients have better outcomes than older white patients. Exploration of this paradoxical finding may lead to a better understanding of the mechanisms that cause disparities in trauma outcomes.

African American women's preventative care usage: the role of social support and racial experiences and attitudes

Research suggests that African Americans are less likely to utilise preventative care services than Americans of European descent, and that these patterns may contribute to racial health disparities in the United States. Despite the persistence of inequalities in preventative care utilisation, culturally relevant factors influencing the use of these gateway health services have been understudied among marginalised groups. Using a stratified sample of 205 low-income African American women, this research examines the predictors of receiving a physical exam, with a particular emphasis on how differing levels of social support from friend and family networks and experiences of racial discrimination and cultural mistrust shape utilisation. The findings underscore the importance of traditional predictors of utilisation, including insurance status and having a usual physician. However, they also indicate that supportive ties to friendship networks are associated with higher predicted rates of having an annual physical exam, while social support from family and sentiments of cultural mistrust are associated with lower rates of utilisation. Broadly, the findings indicate that even as traditional predictors of help-seeking become less relevant, it will be critical to explore how variations in discrimination experiences and social relationships across marginalised groups drive patterns of preventative care utilisation.

"You learn to go last": perceptions of prenatal care experiences among African-American women with limited incomes

African American infants die at higher rates and are at greater risk of adverse birth outcomes than White infants in Milwaukee. Though self-reported experiences of racism have been linked to adverse health outcomes, limited research exists on the impact of racism on women's prenatal care experiences. The purpose of this study was to examine the experiences of racial discrimination during prenatal care from the perspectives of African American women in a low income Milwaukee neighborhood. Transcripts from six focus groups with twenty-nine women and two individual interviews were analyzed to identify important emergent themes. Validity was maintained using an audit trail, peer debriefing, and two individual member validation sessions. Participants identified three areas of perceived discrimination based on: (1) insurance or income status, (2) race, and (3) lifetime experiences of racial discrimination. Women described being treated differently by support staff and providers based on type of insurance (public versus private), including perceiving a lower quality of care at clinics that accepted public insurance. While some described personally-mediated racism, the majority of women described experiences that fit within a definition of institutionalized racism-in which the system was designed in a way that worked against their attempts to get quality prenatal care. Women also described lifetime experiences of racial discrimination. Our findings suggest that African American women with limited incomes perceive many provider practices and personal interactions during prenatal care as discriminatory. Future studies could explore the relationship between perceptions of discrimination and utilization of prenatal care.

Experiencing racism in health care: the mental health impacts for Victorian Aboriginal communities

OBJECTIVES

To examine experiences of racism in health settings and their impact on mental health among Aboriginal Australians.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey of experiences of racism and mental health was conducted in two metropolitan and two rural Victorian local government areas (LGAs) between 1 December 2010 and 31 October 2011. Participants included 755 Aboriginal Australians aged over 18 years who had resided in the relevant LGA for at least a year. The response rate across all LGAs was 99%.

MAIN OUTCOME MEASURES

Being above or below the threshold for high or very high psychological distress on the Kessler Psychological Distress Scale.

RESULTS

221 participants reported experiences of racism in health settings in the past 12 months. The results suggested that people experiencing racism in health settings (OR, 4.49; 95% CI, 2.28-8.86) and non-health settings (OR, 2.66; 95% CI, 1.39-5.08) were more likely than people who did not experience racism to be above the threshold for high or very high psychological distress.

CONCLUSIONS

Experiencing interpersonal racism in health settings is associated with increased psychological distress over and above what would be expected in other settings. This finding supports the rationale for improving cultural competency and reducing racism as a means of closing the health gap between Aboriginal and other Australians. Capitalising on this investment will require explicitly evaluating the impact of these initiatives on reducing patient experiences of racism.

Quality of follow-up after hospitalization for mental illness among patients from racial-ethnic minority groups

OBJECTIVE

Outpatient follow-up after hospitalization for mental health reasons is an important indicator of quality of health systems. Differences among racial-ethnic minority groups in the quality of service use during this period are understudied. This study assessed the quality of outpatient treatment episodes following inpatient psychiatric treatment among blacks, whites, and Latinos in the United States.

METHODS

The Medical Expenditure Panel Survey (2004-2010) was used to identify adults with any inpatient psychiatric treatment (N=339). Logistic regression models were used to estimate predictors of any outpatient follow-up or the beginning of adequate outpatient follow-up within seven or 30 days following discharge. Predicted disparities were calculated after adjustment for clinical need variables but not for socioeconomic characteristics, consistent with the Institute of Medicine definition of health care disparities as differences that are unrelated to clinical appropriateness, need, or patient preference.

RESULTS

Rates of follow-up were generally low, particularly rates of adequate treatment (<26%). Outpatient treatment prior to inpatient care was a strong predictor of all measures of follow-up. After adjustment for need and socioeconomic status, the analyses showed that blacks were less likely than whites to receive any treatment or begin adequate follow-up within 30 days of discharge.

CONCLUSIONS

Poor integration of follow-up treatment in the continuum of psychiatric care leaves many individuals, particularly blacks, with poor-quality treatment. Culturally appropriate interventions that link individuals in inpatient settings to outpatient follow-up are needed to reduce racial-ethnic disparities in outpatient mental health treatment following acute treatment.

Discrimination based on criminal record and healthcare utilization among men recently released from prison: a descriptive study

BACKGROUND

Healthcare discrimination based on race/ethnicity is associated with decreased healthcare access and utilization among racial/ethnic minority patients. Discrimination based on criminal record may also negatively impact healthcare access and utilization among ex-prisoners.

METHODS

We conducted a secondary analysis of data from a cross-sectional survey of 172 men recently released from state prison. We examined the association between self-reported criminal record discrimination by healthcare workers and utilization of 1) emergency department (ED) and 2) primary care services. We created staged logistic regression models, adjusting for sociodemographic characteristics and self-reported racial/ethnic discrimination.

RESULTS

Among 172 male participants, 42% reported a history of criminal record discrimination by healthcare workers. Participants who reported discrimination were older (mean, 42 vs. 39 years; p = .01), more likely to be college educated (26% vs. 11%; p = .03), and had more extensive incarceration histories (median years incarcerated, 16 vs. 9; p = .002) compared to those who did not report discrimination. Self-reported criminal record discrimination by healthcare workers was significantly associated with frequent ED utilization [odds ratio (OR) = 2.7, 95% confidence interval 24 (CI) 1.2-6.2] but not infrequent primary care utilization [OR = 1.6, 95% CI 0.7-3.8].

CONCLUSIONS

Recently released prisoners report criminal record discrimination by healthcare workers, and this experience may impact healthcare utilization. Future studies should seek to further characterize criminal record discrimination by healthcare workers and prospectively examine its impact on health outcomes.

Medical mistrust, perceived discrimination, and satisfaction with health care among young-adult rural latinos

PURPOSE

Little research has analyzed mistrust and discrimination influencing receipt of health care services among Latinos, particularly those living in rural areas. This study examined the associations between medical mistrust, perceived discrimination, and satisfaction with health care among young-adult rural Latinos.

RESEARCH DESIGN

This cross-sectional study analyzed data from 387 young-adult Latinos (ages 18-25) living in rural Oregon. The Behavioral Model of Vulnerable Populations was utilized as the theoretical framework. Correlations were run to assess bivariate associations among variables included in the study. Ordered logistic regression models evaluated the associations between medical mistrust, perceived discrimination, and satisfaction with health care.

RESULTS

On average, participants used health services 4 times in the past year. Almost half of the participants had health insurance (46%). The majority reported that they were moderately (32%) or very satisfied (41%) with health care services used in the previous year. In multivariable models, medical mistrust and perceived discrimination were significantly associated with satisfaction with health care.

CONCLUSIONS

Medical mistrust and perceived discrimination were significant contributors to lower satisfaction with health care among young-adult Latinos living in rural Oregon. Health care reform implementation, currently under way, provides a unique opportunity for developing evaluation systems and interventions toward monitoring and reducing rural Latino health care disparities.

A systematic review of the extent and measurement of healthcare provider racism

BACKGROUND

Although considered a key driver of racial disparities in healthcare, relatively little is known about the extent of interpersonal racism perpetrated by healthcare providers, nor is there a good understanding of how best to measure such racism.

OBJECTIVES

This paper reviews worldwide evidence (from 1995 onwards) for racism among healthcare providers; as well as comparing existing measurement approaches to emerging best practice, it focuses on the assessment of interpersonal racism, rather than internalized or systemic/institutional racism.

METHODS

The following databases and electronic journal collections were searched for articles published between 1995 and 2012: Medline, CINAHL, PsycInfo, Sociological Abstracts. Included studies were published empirical studies of any design measuring and/or reporting on healthcare provider racism in the English language. Data on study design and objectives; method of measurement, constructs measured, type of tool; study population and healthcare setting; country and language of study; and study outcomes were extracted from each study.

RESULTS

The 37 studies included in this review were almost solely conducted in the U.S. and with physicians. Statistically significant evidence of racist beliefs, emotions or practices among healthcare providers in relation to minority groups was evident in 26 of these studies. Although a number of measurement approaches were utilized, a limited range of constructs was assessed.

CONCLUSION

Despite burgeoning interest in racism as a contributor to racial disparities in healthcare, we still know little about the extent of healthcare provider racism or how best to measure it. Studies using more sophisticated approaches to assess healthcare provider racism are required to inform interventions aimed at reducing racial disparities in health.

A systematic review of barriers and facilitators to minority research participation among African Americans, Latinos, Asian Americans, and Pacific Islanders

To assess the experienced or perceived barriers and facilitators to health research participation for major US racial/ethnic minority populations, we conducted a systematic review of qualitative and quantitative studies from a search on PubMed and Web of Science from January 2000 to December 2011. With 44 articles included in the review, we found distinct and shared barriers and facilitators. Despite different expressions of mistrust, all groups represented in these studies were willing to participate for altruistic reasons embedded in cultural and community priorities. Greater comparative understanding of barriers and facilitators to racial/ethnic minorities' research participation can improve population-specific recruitment and retention strategies and could better inform future large-scale prospective quantitative and in-depth ethnographic studies.

Structural racism and myocardial infarction in the United States

There is a growing research literature suggesting that racism is an important risk factor undermining the health of Blacks in the United States. Racism can take many forms, ranging from interpersonal interactions to institutional/structural conditions and practices. Existing research, however, tends to focus on individual forms of racial discrimination using self-report measures. Far less attention has been paid to whether structural racism may disadvantage the health of Blacks in the United States. The current study addresses gaps in the existing research by using novel measures of structural racism and by explicitly testing the hypothesis that structural racism is a risk factor for myocardial infarction among Blacks in the United States. State-level indicators of structural racism included four domains: (1) political participation; (2) employment and job status; (3) educational attainment; and (4) judicial treatment. State-level racial disparities across these domains were proposed to represent the systematic exclusion of Blacks from resources and mobility in society. Data on past-year myocardial infarction were obtained from the National Epidemiologic Survey on Alcohol and Related Conditions (non-Hispanic Black: N = 8245; non-Hispanic White: N = 24,507), a nationally representative survey of the U.S. civilian, non-institutionalized population aged 18 and older. Models were adjusted for individual-level confounders (age, sex, education, household income, medical insurance) as well as for state-level disparities in poverty. Results indicated that Blacks living in states with high levels of structural racism were generally more likely to report past-year myocardial infarction than Blacks living in low-structural racism states. Conversely, Whites living in high structural racism states experienced null or lower odds of myocardial infarction compared to Whites living in low-structural racism states. These results raise the provocative possibility that structural racism may not only harm the targets of stigma but also benefit those who wield the power to enact stigma and discrimination.

Racial and socioeconomic disparities in presentation and outcomes of well-differentiated thyroid cancer

CONTEXT

Racial/ethnic minorities suffer disproportionate morbidity and mortality from chronic diseases.

OBJECTIVE

Our objective was to assess racial and socioeconomic status (SES) disparities in well-differentiated thyroid cancer (WDTC) patients.

DESIGN AND PARTICIPANTS

We conducted a retrospective cohort study on 25 945 patients with WDTC (1999-2008) from the California Cancer Registry (57% white, 4% black, 24% Hispanic, and 15% Asian-Pacific Islander [API]).

MAIN OUTCOMES

We evaluated effect of race and SES variables on stage of cancer presentation and overall/disease-specific survival.

RESULTS

Significant differences in stage of presentation between all racial groups were found (P<.001), with minority groups presenting with a higher percentage of metastatic disease as compared with white patients (black, odds ratio [OR]=1.36 with confidence interval [CI] 1.01-1.84; Hispanic, OR=1.89 [CI, 1.62-2.21], API, OR=1.82 [CI, 1.54-2.15]). Hispanic (OR=1.59, [CI, 1.48-1.72]) and API (OR=1.32 [1.22-1.44]) patients also presented with higher odds of regional disease. Patients with the lowest SES presented with metastatic disease more often than those with the highest SES (OR=1.45 [CI, 1.16-1.82]). Those that were poor/uninsured and/or with Medicaid insurance had higher odds of presenting with metastatic disease as compared with those with private insurance (OR=2.41, [CI, 2.10-2.77]). Unadjusted overall survival rates were higher among API and Hispanic patients and lower among black patients (P<.001 vs white patients). Adjusted overall survival also showed a survival disadvantage for black patients (hazard ratio=1.4, [CI, 1.10-1.73]) and survival advantage for API patients (hazard ratio=0.83, [CI, 0.71-0.97]). In disease-specific survival analyses, when only those patients with metastatic disease were analyzed separately, black patients again had the lowest survival rates, and Hispanic/API patients had the highest survival rates (P<.04).

CONCLUSION

Black patients and those with low SES have worse outcomes for thyroid cancer. API and Hispanic patients may have a protective effect on survival despite presenting with more advanced disease.

Satisfaction with pain treatment in older cancer patients: Identifying variants of discrimination, trust, communication, and self-efficacy

How satisfied a patient is with their medical treatment may influence compliance and adherence to medical regimens. While a number of studies have examined patient satisfaction among younger populations, few have determined the impact social factors have on satisfaction with pain treatment among older adults. This study aimed to determine the influence discrimination, trust, communication, and other health characteristics have on satisfaction with pain treatment among older adults receiving outpatient services from a comprehensive cancer center. Participants were surveyed on questions assessing pain symptomatology, and identified social (discrimination, trust, and communication), physical (comorbidities, pain interference), behavioral (self-efficacy), and demographic characteristics. Analyses were calculated to determine the total and indirect effects of trust, communication, and self-efficacy as mediators on the perceived discrimination-patient satisfaction with pain treatment relationship. Data showed a significant relationship of communication and discrimination on patient satisfaction. However, none of the mediating effects were significant. It must be recognized that patient satisfaction is contingent upon a myriad of social factors that are not exclusive, but rather coexisting determinants of health. Particularly among the elderly, perceived discrimination and incidences of poor communication may be significant influences on health and the lived day-to-day experiences of this adult population.

Healthcare disparities in critical illness

OBJECTIVE

To summarize the current literature on racial and gender disparities in critical care and the mechanisms underlying these disparities in the course of acute critical illness.

DATA SOURCES

MEDLINE search on the published literature addressing racial, ethnic, or gender disparities in acute critical illness, such as sepsis, acute lung injury, pneumonia, venous thromboembolism, and cardiac arrest.

STUDY SELECTION

Clinical studies that evaluated general critically ill patient populations in the United States as well as specific critical care conditions were reviewed with a focus on studies evaluating factors and contributors to health disparities.

DATA EXTRACTION

Study findings are presented according to their association with the prevalence, clinical presentation, management, and outcomes in acute critical illness.

DATA SYNTHESIS

This review presents potential contributors for racial and gender disparities related to genetic susceptibility, comorbidities, preventive health services, socioeconomic factors, cultural differences, and access to care. The data are organized along the course of acute critical illness.

CONCLUSIONS

The literature to date shows that disparities in critical care are most likely multifactorial involving individual, community, and hospital-level factors at several points in the continuum of acute critical illness. The data presented identify potential targets as interventions to reduce disparities in critical care and future avenues for research.

Disparities in race/ethnicity and socioeconomic status: risk of mortality of breast cancer patients in the California Cancer Registry, 2000-2010

BACKGROUND

Racial disparities in breast cancer survival have been well documented. This study examines the association of race/ethnicity and socioeconomic status (SES) on breast cancer-specific mortality in a large population of women with invasive breast cancer.

METHODS

We identified 179,143 cases of stages 1-3 first primary female invasive breast cancer from the California Cancer Registry from January, 2000 through December, 2010. Cox regression, adjusted for age, year of diagnosis, grade, and ER/PR/HER2 subtype, was used to assess the association of race/ethnicity on breast cancer-specific mortality within strata of stage and SES. Hazard ratios (HR) and 95% confidence intervals were reported.

RESULTS

Stage 1: There was no increased risk of mortality for any race/ethnicity when compared with whites within all SES strata. Stage 2: Hispanics (HR = 0.85; 0.75, 0.97) in the lowest SES category had a reduced risk of mortality.. Blacks had the same risk of mortality as whites in the lowest SES category but an increased risk of mortality in the intermediate (HR = 1.66; 1.34, 2.06) and highest (HR = 1.41; 1.15, 1.73) SES categories. Stage 3: Hispanics (HR = 0.74; 0.64, 0.85) and APIs (HR = 0.64; 0.50, 0.82) in the lowest SES category had a reduced risk while blacks had similar mortality as whites. Blacks had an increased risk of mortality in the intermediate (HR = 1.52; 1.20, 1.92) and highest (HR = 1.53; 1.22, 1.92) SES categories.

CONCLUSIONS

When analysis of breast cancer-specific mortality is adjusted for age and year of diagnosis, ER/PR/HER2 subtype, and tumor grade and cases compared within stage and SES strata, much of the black/white disparity disappears. SES plays a prominent role in breast cancer-specific mortality but it does not fully explain the racial/ethnic disparities and continued research in genetic, societal, and lifestyle factors is warranted.

Race, life course socioeconomic position, racial discrimination, depressive symptoms and self-rated health

Greater levels of socioeconomic position (SEP) are generally associated with better health. However results from previous studies vary across race/ethnicity and health outcomes. Further, the majority of previous studies do not account for the effects of life course SEP on health nor the effects of racial discrimination, which could moderate the effects of SEP on health. Using data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, we examined the relationship between a life course SEP measure on depressive symptoms and self-rated health. A life course SEP was constructed for each participant, using a framework that included parental education and occupation along with respondents' highest level of education and occupation. Interaction terms were created between life course SEP and racial discrimination to determine whether the association between SEP and health was moderated by experiences of racial discrimination. Analyses revealed that higher levels of life course SEP were inversely related to depressive symptoms. Greater life course SEP was positively associated with favorable self-rated health. Racial discrimination was associated with more depressive symptoms and poorer self-rated health. Analyses indicated a significant interaction between life course SEP and racial discrimination on depressive symptoms in the full sample. This suggested that for respondents with greater levels of SEP, racial discrimination was associated with reports of more depressive symptoms. Future research efforts should be made to examine whether individuals' perceptions and experiences of racial discrimination at the interpersonal and structural levels limits their ability to acquire human capital as well as their advancement in education and occupational status.

Health-Related Stereotype Threat Predicts Health Services Delays Among Blacks

To our knowledge, no published research has developed an individual difference measure of health-related stereotype threat (HRST). We adapted existing measures of academic stereotype threat to the health domain on a sample of black college students (N = 280). The resulting health-related stereotype threat scale-24 (HRST-24) was assessed for internal consistency, construct and incremental validity, and whether it explains variance in self-reported delays among four preventive health behaviors-blood pressure and cholesterol assays, physical exams, and routine checkups. After adjusting for several control variables, the HRST-24's (full scale α = 0.96) perceived black health inferiority (18 items; α = 0.96) and perceived physician racial bias (6 items; α = 0.85) sub-scales explained unique variance in delays among two of the four behaviors including a blood cholesterol check (p < .01) and routine checkup-albeit at marginal levels (p = .063) in the case of the latter. Overall, these data provide preliminary evidence of construct and incremental validity for the HRST-24 among blacks. Recommendations for administering the scale are provided and future directions for HRST research are discussed.

A multidisciplinary survey on discrimination analysis

The collection and analysis of observational and experimental data represent the main tools for assessing the presence, the extent, the nature, and the trend of discrimination phenomena. Data analysis techniques have been proposed in the last 50 years in the economic, legal, statistical, and, recently, in the data mining literature. This is not surprising, since discrimination analysis is a multidisciplinary problem, involving sociological causes, legal argumentations, economic models, statistical techniques, and computational issues. The objective of this survey is to provide a guidance and a glue for researchers and anti-discrimination data analysts on concepts, problems, application areas, datasets, methods, and approaches from a multidisciplinary perspective. We organize the approaches according to their method of data collection as observational, quasi-experimental, and experimental studies. A fourth line of recently blooming research on knowledge discovery based methods is also covered. Observational methods are further categorized on the basis of their application context: labor economics, social profiling, consumer markets, and others.

Relationships between discrimination in health care and health care outcomes among four race/ethnic groups

Discrimination has been found to be detrimental to health, but less is known about the influence of discrimination in health care. To address this, the current study (1) compared levels of racial/ethnic discrimination in health care among four race/ethnic groups; (2) determined associations between this type of discrimination and health care outcomes; and (3) assessed potential mediators and moderators as suggested by previous studies. Multivariate logistic regression models were used within a population-based sample of 1,699 White, African American, Mexican, and Puerto Rican respondents. Overall, 23% of the sample reported discrimination in health care, with levels varying substantially by race/ethnicity. In adjusted models, this type of discrimination was associated with an increased likelihood of having unmet health care needs (OR = 2.48, CI = 1.57-3.90) and lower odds of perceiving excellent quality of care (OR = 0.43, CI = 0.28-0.66), but not with the use of a physician when not sick or use of alternative medicine. The mediating role of mental health factors was inconsistently observed and the relationships were not moderated by race/ethnicity. These findings expand the literature and provide preliminary evidence that can eventually inform the development of interventions and the training of health care providers.

The effect of socioeconomic status on access to primary care: an audit study

BACKGROUND

Health care office staff and providers may discriminate against people of low socioeconomic status, even in the absence of economic incentives to do so. We sought to determine whether socioeconomic status affects the response a patient receives when seeking a primary care appointment.

METHODS

In a single unannounced telephone call to a random sample of family physicians and general practices (n = 375) in Toronto, Ontario, a male and a female researcher each played the role of a patient seeking a primary care physician. Callers followed a script suggesting either high (i.e., bank employee transferred to the city) or low (i.e., recipient of social assistance) socioeconomic status, and either the presence or absence of chronic health conditions (diabetes and low back pain). We randomized the characteristics of the caller for each office. Our primary outcome was whether the caller was offered an appointment.

RESULTS

The proportion of calls resulting in an appointment being offered was significantly higher when the callers presented themselves as having high socioeconomic status than when they presented as having low socioeconomic status (22.6% v.14.3%, p = 0.04) and when the callers stated the presence of chronic health conditions than when they did not (23.5% v. 12.8%, p = 0.008). In a model adjusted for all independent variables significant at a p value of 0.10 or less (presence of chronic health conditions, time since graduation from medical school and membership in the College of Family Physicians of Canada), high socioeconomic status was associated with an odds ratio of 1.78 (95% confidence interval 1.02-3.08) for the offer of an appointment. Socioeconomic status and chronic health conditions had independent effects on the likelihood of obtaining an appointment.

INTERPRETATION

Within a universal health insurance system in which physician reimbursement is unaffected by patients' socioeconomic status, people presenting themselves as having high socioeconomic status received preferential access to primary care over those presenting themselves as having low socioeconomic status.

Discrimination in health care and CAM use in a representative sample of U.S. adults

OBJECTIVES

Discrimination in medical settings may influence patient attitudes about health care and health-seeking behaviors. Patients who experience discrimination may seek alternative means of health care, including use of complementary and alternative medicine (CAM). The objective of this study was to examine the relationship between discrimination in health care and CAM use.

DESIGN

Data come from the 2001 Health Care Quality Survey (HCQS), which used a multistage sampling design with random-digit dialing, oversampling telephone exchanges with higher densities of African-American, Hispanic, and Asian households. The 2001 HCQS sample consisted of 6722 adults living in the continental United States. To correct for the disproportionate sample design, data were adjusted using sample weights to make the results representative of the U.S. population 18 years and older. Present analyses were limited to 6008 respondents who had visited a doctor or clinic or had been admitted to the hospital in the last 2 years.

OUTCOME MEASURES

Outcome measures were CAM use, practitioner-provided CAM use, and herbal medicine use.

RESULTS

In adjusted logistic regression analyses, discrimination in health care was significantly associated with use of herbal medicines alone (adjusted odds ratio=1.47, confidence interval: 1.05, 2.04), but not with use of practitioner-provided CAM (i.e., use of acupuncture, chiropractor, traditional healer or herbalist, alone or in combination with herbal medicines).

CONCLUSIONS

Further research is needed to examine the direction of the relationship between discrimination and CAM use and differences by CAM modality.

Racial Healthcare Disparities: A Social Psychological Analysis

Around the world, members of racial/ethnic minority groups typically experience poorer health than members of racial/ethnic majority groups. The core premise of this article is that thoughts, feelings, and behaviors related to race and ethnicity play a critical role in healthcare disparities. Social psychological theories of the origins and consequences of these thoughts, feelings, and behaviors offer critical insights into the processes responsible for these disparities and suggest interventions to address them. We present a multilevel model that explains how societal, intrapersonal, and interpersonal factors can influence ethnic/racial health disparities. We focus our literature review, including our own research, and conceptual analysis at the intrapersonal (the race-related thoughts and feelings of minority patients and non-minority physicians) and interpersonal levels (intergroup processes that affect medical interactions between minority patients and non-minority physicians). At both levels of analysis, we use theories of social categorization, social identity, contemporary forms of racial bias, stereotype activation, stigma, and other social psychological processes to identify and understand potential causes and processes of health and healthcare disparities. In the final section, we identify theory-based interventions that might reduce ethnic/racial disparities in health and healthcare.

Gender eugenics? The ethics of PGD for intersex conditions

This article discusses the ethics of the use of preimplantation genetic diagnosis (PGD) to prevent the birth of children with intersex conditions/disorders of sex development (DSDs), such as congenital adrenal hyperplasia (CAH) and androgen insensitivity syndrome (AIS). While pediatric surgeries performed on children with ambiguous genitalia have been the topic of intense bioethical controversy, there has been almost no discussion to date of the ethics of the use of PGD to reduce the prevalence of these conditions. I suggest that PGD for those conditions that involve serious medical risks for those born with them is morally permissible and that PGD for other "cosmetic" variations in sexual anatomy is more defensible than might first appear. However, importantly, the arguments that establish the latter claim have radical and disturbing implications for our attitude toward diversity more generally.

Perceived experiences of discrimination in health care: a barrier for cancer screening among American Indian women with type 2 diabetes

PURPOSE

Breast and cervical cancer-mortality disparities are prominent among American Indian women. These disparities, in part, may result from patients perceived experiences of discrimination in health care. This report evaluates the impact of perceived discrimination on screening for breast and cervical cancer in a sample of 200 American Indian women with type 2 diabetes.

METHODS

Data were collected from patient report and medical records. Prevalence of breast and cervical cancer screening were assessed. Unadjusted and adjusted logistic regression analyses were used to assess associations between perceived discrimination, cancer screening status, and patients' health care-seeking behaviors.

FINDINGS

Substantial proportions of AI women in our sample were behind the recommended schedules of screening for breast and cervical cancer. Adjusted estimates revealed that perceived discrimination was significantly associated with not being current for clinical breast examination and Pap test, and was close to statistical significance with not being current for mammography. The number of suboptimal health care-seeking behaviors increased with higher mean levels of perceived discrimination.

CONCLUSIONS

Among AI women, perceived discrimination in health care may negatively influence use of breast and cancer screening services, and health care-seeking behaviors. More research is needed among AIs to examine features of health care systems related to the phenomenon patients perceived experience of discrimination.

The relationship between perceived discrimination and patient experiences with health care

BACKGROUND

Prior studies have shown that racial/ethnic minorities have lower Consumer Assessments of Healthcare Providers and Systems (CAHPS) scores. Perceived discrimination may mediate the relationship between race/ethnicity and patient experiences with care.

OBJECTIVE

To examine the relationship between perceived discrimination based on race/ethnicity and Medicaid insurance and CAHPS reports and ratings of care.

METHODS

The study analyzed 2007 survey data from 1509 Florida Medicaid beneficiaries. CAHPS reports (getting needed care, timeliness of care, communication with doctor, and health plan customer service) and ratings (personal doctor, specialist care, overall health care, and health plan) of care were the primary outcome variables. Patient perceptions of discrimination based on their race/ethnicity and having Medicaid insurance were the primary independent variables. Regression analysis modeled the effect of perceptions of discrimination on CAHPS reports and ratings controlling for age, sex, education, self-rated health status, race/ethnicity, survey language, and fee-for-service enrollment. SEs were corrected for correlation within plans.

RESULTS

Medicaid beneficiaries reporting discrimination based on race/ethnicity had lower CAHPS scores, ranging from 15 points lower (on a 0-100 scale) for getting needed care to 6 points lower for specialist rating, compared with those who never experienced discrimination. Similar results were obtained for perceived discrimination based on Medicaid insurance.

CONCLUSIONS

Perceptions of discrimination based on race/ethnicity and Medicaid insurance are prevalent and are associated with substantially lower CAHPS reports and ratings of care. Practices must develop and implement strategies to reduce perceived discrimination among patients.