Reducing racial, ethnic, and socioeconomic disparities in health care: opportunities in national health reform

Exploring Barriers to the Inclusion of Underrepresented Minorities in Urology: The Temporal and Financial Costs of Residency Interviews

OBJECTIVE

To investigate whether interview travel cost and time differed for urology residency applicants from medical schools with higher versus lower proportions of students from groups underrepresented in medicine (URiMs).

METHODS

We identified 22 medical schools, 11 with <15% and 11 with >20% URiM students, and 17 "highly ranked" urology residency programs. We contacted the residency programs and requested interview dates, preferred lodging options, and institution-based cost-savings. We constructed interview itineraries for 22 hypothetical students (one from each school), and compared the total cost and time for travel to all 17 interviews. Total travel time and interview costs for the students at schools with <15% and >20% URiM were compared, with findings considered statistically significant at p<0.05.

RESULTS

Each student was able to attend all 17 interviews. The median total cost was similar for applicants from schools >20% URiM ($8074.80; range: $7027.60-$13,702.59) and <15% URiM ($8764.60; range: $6698.48-$11966.83; p=0.89). The median aggregate travel time for applicants from schools >20% URiM was 176.4 (range: 93.7-246.2) hours and for applicants from schools <15% URiM was 160.5 (range: 128.2-203.9) hours (p=0.62).

CONCLUSIONS

Financial and temporal costs were similar for applicants from medical schools with <15% or >20% URiM students. Thus, absolute cost considerations are unlikely to account for differences in URiM representation in urology. However, the relative impact of interview costs may be different for URiM students. Effective and durable engagement of URiM students in urology requires an introspective assessment of objective versus anecdotal barriers to recruiting and retaining URiM medical students.

Is Patient-Provider Racial Concordance Associated with Hispanics' Satisfaction with Health Care?

This study adds a gender approach to determine how patient provider racial concordance and acculturation affect Hispanics’ satisfaction with care and inform more nuanced approaches to improving the quality of care for this population. Using the Medical Expenditure Panel Surveys (MEPS) from 2009–2011, four binary satisfaction outcome measures were created from the MEPS: “doctor showed respect”, “spent enough time”, “explained things in a way you could understand”, and “listened carefully”. Next, a Probit model was employed to estimate the impact of racial concordance and acculturation on the probability of being satisfied with provider care for both male and female Hispanics. For Hispanic women, no significant association was found for the relationship between patient-provider concordance and the overall satisfaction with their care. Hispanic men were found to be less likely to be satisfied with some aspects of their medical care when they were racially concordant with their provider. Overcoming assumptions about shared identity is a crucial step in providing culturally competent care for all patients. There is a need for additional considerations in medical training to help physicians connect with patients, regardless of any type of observable concordance.

For Better or Worse? Change in Service Use by Children Investigated by Child Welfare Over a Decade

BACKGROUND

Children, particularly minority children, referred to child welfare because of suspected maltreatment are vulnerable and need many services. We sought to assess whether service use has improved over the past decade and whether racial-ethnic disparities in service use have decreased.

METHODS

We used 2 national data sets (the National Survey of Child and Adolescent Well-Being [NSCAW] I and II) collected a decade apart to assess changes over time in health, education, mental health (MH), and dental services and overall service use.

RESULTS

In NSCAW II more children were young, had lower Child Behavior Checklist (CBCL) scores, and were Hispanic. We found significant increases in dental services, a decrease in special education services, and a decrease in MH services on the bivariate level (all P < .01). A large proportion of the change in MH services occurred in school settings, but the pattern continued when examining only those services delivered outside of school. The greatest decrease occurred for children with CBCL scores <64. However, in multivariate analyses, older children, white non-Hispanic children, and children placed out of the home were significantly more likely to receive MH services. Rates of MH services controlling for CBCL scores showed no improvement over the decade, nor was there a decrease in racial and ethnic disparities.

CONCLUSIONS

These data showed no change in MH services over time for children referred for child welfare evaluation, but improvement in dental services was noted. Racial and ethnic disparities persist. Decrease in MH services occurred predominantly among children whose MH symptoms were below the clinical range.

Health care access and utilization among US-born and foreign-born Asian Americans

Despite efforts to eliminate inequality in health and health care, disparities in health care access and utilization persist in the United States. The purpose of this study was to compare the access to care and use of health care services of US-born and foreign-born Asian Americans. We used aggregated data from the National Health Interview Survey (NHIS) from 2003 to 2005, including 2,500 participants who identified themselves as Asian. Associations between country of birth and reported access and utilization of care in the previous 12 months were examined. After controlling for covariates, being foreign-born was negatively related to indicators of access to care, including health insurance (OR = 0.29, 95%CI = 0.18-0.48), routine care access (OR = 0.52, 95%CI = 0.36-0.75), and sick care access [OR = 0.67, 95%CI = 0.47-0.96)]. Being foreign-born was also negatively related to all indicators of health care utilization (office visit: OR = 0.58, 95%CI = 0.41-0.81; seen/talked to a general doctor: OR = 0.69, 95%CI = 0.52-0.90; seen/talked to a specialist: OR = 0.42, 95%CI = 0.28-0.63) but ER visit (OR = 0.84, 95%CI = 0.59-1.20). There are substantial differences by country of birth in health care access and utilization among Asian Americans. Our findings emphasize the need for developing culturally sensitive health services and intervention programs for Asian communities.