In this nationally representative sample, we found bi-directional racial differences in receipt of preventive services. Despite being less likely to report having a usual source of care, black and Hispanic women were as likely or more likely to report receiving breast and cervical cancer screening than white women. In contrast, Hispanics reported receiving blood pressure screening less often than whites and blacks reported receiving cholesterol screening more often. In addition, for each race/ethnicity, having a USOC was strongly and independently associated with receiving preventive services, even after controlling for other factors. However, controlling for USOC and other confounders attenuated, but did not eliminate, differences by race in receipt of each preventive service.
Despite an increasing body of literature describing racial disparities in health care, we found less racial variation between whites and nonwhites in receipt of female preventive services. The results we report are supported by other data that have shown comparable and increasing rates of breast and cervical screening services over the last decade.12,27–29
These trends may be in part due to increased public awareness since the 1980s of the importance of timely breast and cervical cancer screening. The rates we and others report may also reflect national initiatives such as Healthy People 2000 and the National Breast and Cervical Cancer Early Detection Program, which have focused professional attention on female cancer screening.30,31
However, despite remediation of racial differences in female screening, differences by race/ethnicity and socioeconomic status still remain for survival for breast and cervical cancers.32,33
Consistent differences by race/ethnicity have been documented for the primary and secondary prevention of vascular diseases. Other authors have described that despite a higher prevalence of hypertension in certain subgroups, Hispanics are less likely to receive hypertensive care and less likely to have adequate blood pressure control.34,35
However, our findings of more cholesterol screening among black patients are in conflict with results reported by other authors. Patients of white race and those that held private insurance, rather than Medicaid, have been reported to have the highest likelihood of receiving cholesterol screening.36–38
In trying to reconcile our findings, we wondered if clustering of cardiovascular risk factors might help explain higher levels of cholesterol screening, since clinicians evaluate a patient's cardiovascular risk, including the presence of other conditions that may put patients at higher risk of disease.39
Given that a history of hypertension may be considered an indication for cholesterol screening, we examined the association between blood pressure and cholesterol screens. In fact, in regression models, having had blood pressure screening was the most powerful predictor of cholesterol screening, more powerful than having a USOC.
In addition, our finding of an absence of interaction between race/ethnicity and having USOC (i.e., having a USOC was associated with receiving preventive services, regardless of race/ethnic group) suggests that improving access to a regular source of care may be an important step in improving receipt of preventive services by all racial and ethnic groups. Respondents who identified a USOC were 2 to 3 times more likely to receive the examined preventive services. However, it is not clear from these analyses, or from the literature, how or whether the type of provider might further influence the relation between race/ethnicity and the receipt of preventive services. Others have shown that having a regular source of care may be the most important factor in receiving preventive services.9,19,21,40–42
However, there is evidence that providing entry into the health system without continuity or other elements of primary care may not be sufficient to ensure receipt of preventive services.43,44
O'Malley reported that in the setting of female cancer screening, higher levels of cancer screening are associated with greater levels of continuity of care among uninsured ethnic minority women.19
Although these data highlight the role of having a USOC in addressing health disparities, because of the limitations of this and other reports, the added impact of a continuous relationship with a specific clinician in improving health outcomes, beyond receiving preventive services, remains unanswered.
Despite the large, nationally representative sample and broad spectrum of preventive services that we were able to examine, this study has limitations. Although the associations we report are strong, the cross-sectional nature of the dataset precludes determining causal relations between race/ethnicity, USOC, and each preventive service. In addition, the HC component of MEPS is based on self-report of receipt of preventive services. There are conflicting data on how well self-reporting of preventive services may correspond with actual utilization.45–47
Self-report of laboratory tests such as cholesterol screening may be especially problematic compared to that of other services because the respondent may not have a clear understanding of which blood tests were ordered.48
In addition to the above methodological limitations, although we were able to include Hispanic ethnicity as a variable in our analysis, we were not able to capture the heterogeneity of this or the other race/ethnicity categories. Because of the limitations of MEPS coding, we also realize that in some instances the time periods for receipt of preventive services that we used were approximations of the U.S. Preventive Services Task Force guidelines and could be challenged. To assess the impact, we examined certain preventive services using more strict guidelines and didn't find an important difference in the results. Also, while other authors have attempted to control for the number of comorbid illnesses, we decided, because of the constraints of the dataset and conflicting interpretations in the literature, not to control for comorbid illnesses in our analyses. Finally, our definition of USOC could be disputed by other authors, who describe USOC in broader terms (e.g., including emergency departments) or more narrowly defined terms (e.g., dividing into specific sites where care is sought).
How can these results be used to address disparities in health outcomes? First, we believe it may be instructive to examine why, thus far, we have been successful in reducing disparities in such indicators of access as breast and cervical cancer screening. These successes might inform the path to eliminating disparities in other indicators and reducing disparities in outcomes for breast and cervical cancer. For example, in reducing morbidity and mortality from breast and cervical cancer, health policies may need to broaden from a focus on screening to include improving access to diagnostic and therapeutic options. In addition, although having a USOC will be important in narrowing the differences by race in receipt of preventive services, attending to other factors that contribute to disparities in health will also be essential.
In conclusion, in a nationally representative sample of U.S. adults, we found a bi-directional pattern of racial differences in receipt of preventive services. Controlling for a usual source of care attenuated differences by race/ethnicity but did not eliminate them. These results highlight the inherently complex task of addressing disparities in health outcomes. To this end, successful and unsuccessful initiatives to improve receipt of preventive services should be closely examined and contrasted. The lessons learned should then be used to construct diverse and distinct strategies to address disparities in health outcomes.