The initial electronic literature search generated 1,098 titles and abstracts. An additional 7 titles were added through manual and automated update searches. After applying inclusion and exclusion criteria at the abstract level, 171 full-text articles were reviewed and sorted by clinical content area, as shown in Figure . Details of these studies including sample sizes and other study characteristics are available in the Appendix
Search and selection of literature. CVD cardiovascular disease, HIV human immunodeficiency virus infection, HCV hepatitis C virus infection.
In Table , we present numbers of studies in which disparities were found, and not found, by clinical content area. In the table, a single study might contribute to both columns if the study found disparities in 1 measure of quality or utilization and no disparities in another measure. Most second-generation studies in our review examined potential sources of disparities (e.g., patient trust) without examining actual disparities in quality or utilization. These studies did not contribute data to either column of the table. Table presents similar data stratified by categories of utilization and quality measures.
Presence of Disparities by Clinical Content Area*
Presence of Disparities by Utilization or Outcome Measure*
Tables and are intended not for statistical comparisons but as qualitative “balance sheets” to provide a broad overview of first-generation disparities studies in the VA. There are several points worth noting. First, there is no indication that disparities are more prevalent in some clinical content areas than others. Second, disparities appear most prevalent for surgery and other invasive procedures and medication adherence, processes that are likely to be affected by the quantity and quality of patient–provider communication, shared decision making, and patient participation. Third, in studies examining quality indicators that represent intermediate health outcomes, non-white patients generally fared worse than whites. This potentially indicates that disparities in service intensity are contributing to real disparities in health outcomes, or that minorities are receiving fewer and lower quality services despite greater need, as reflected by less adequate chronic illness management, or both. Finally, because white patients tend to use non-VA care more often than non-white patients do, studies that do not capture non-VA utilization, particularly those using administrative data, may underestimate the degree of disparities, find disparities to be absent when they in fact exist,3
or find “reverse” disparities (non-whites receive more/better care) when in fact no disparities exist.4
Two studies demonstrated this misleading effect of not capturing non-VA utilization.3,4
Arthritis and pain management
Studies of osteoarthritis and pain management reported racial differences in joint replacement surgery and analgesic medication use that generally indicate less aggressive management of osteoarthritis in African Americans and Latinos compared to whites.5–7
These differences do not appear to be explained by differences in symptom severity, as African Americans tend to report similar if not greater levels of pain compared to whites.8–10
African Americans were generally less willing than whites to undergo joint replacement surgery.11
This greater reluctance appears to be caused by less familiarity with the procedure and worse expectations of surgical outcomes, including postoperative recovery, chronic pain, and functioning.12
African Americans also appear to place greater value than whites on non-medical options for managing arthritis, particularly prayer.13–15
However, the degree to which lower willingness among African-American patients explains observed disparities in joint replacement surgery is unknown.
For some cancers, African Americans are less likely to undergo potentially curative surgical resection, but equally likely to undergo non-surgical interventions, such as chemotherapy and radiation.16–19
Studies exploring possible reasons for this disparity suggest that physicians engage in less effective partnerships with African-American patients and provide them with less information as compared to white patients.20–22
Part of this communication disparity appears to be related to African-American patients’ being less assertive or active in their conversations with physicians. As a result of less effective partnerships and less information exchange between physicians and African-American patients, physicians engender less trust among African American as compared to white patients.20
The degree to which these differences in communication, partnership, and trust actually explain disparities in cancer surgery is unknown.
There were mixed findings across studies on racial disparities in the use of invasive procedures in patients with cardiovascular diseases, but the majority of studies found that non-whites undergo fewer procedures than whites.23–43
In 1 study, an observed disparity in the use of cardiac catheterization was partly caused by greater overuse of the procedure among whites than African Americans.27
Studies found greater aversion to invasive procedures among African Americans compared with whites,26,44–46
as well as lower trust among African Americans and greater emphasis on religion as an alternative to medical care.41,47
Notably, African Americans were less familiar with cardiovascular procedures, and this lack of familiarity helped explain racial differences in willingness to undergo procedures in 1 study.46
Patient–physician communication behaviors differed between African American and white patients. One study identified a cycle of passivity in which African American patients, and patients interacting with race discordant physicians, received less information overall because they engaged less often in communication behaviors (e.g., questions, assertions) that typically elicit more information from doctors.48
In focus groups, African-American patients placed greater emphasis on the need for trust in their physicians in deciding about invasive procedures, whereas white patients placed greater emphasis on clinical indications.49
Whereas racial differences were apparent in factors that might influence the use of cardiac care—e.g., aversion to surgery, trust, communication—studies that were able to examine the influence of these factors on the actual use of invasive procedures generally found that they did not explain observed disparities. Physician decision making was more influential, and in 1 study physician recommendations helped explain racial disparities in cardiac procedure use, even after accounting for clinical variables and severity of coronary disease.41
African Americans were more likely to delay seeking treatment for heart failure symptoms and were less adherent (both intentionally and unintentionally) to medication regimens.50
Among patients with peripheral arterial disease, African Americans and Latinos had higher rates of limb amputation.43
The reasons underlying these findings of lower adherence and later presentation were not investigated.
Mental health and substance abuse
Clinicians tend to more frequently diagnose and treat African-American patients with mental illness as having psychotic disorders (e.g., schizophrenia) and white patients as having affective disorders (e.g., bipolar disorder, depression).51,52
The underlying causes of these disparities in diagnostic and treatment patterns remain unclear.
Studies investigating the effect of the “racial environment” on mental health and substance abuse outcomes suggest that African-American patients may derive benefit from having a racially concordant clinician, and from being in a racially concordant treatment group.53,54
Preventive and ambulatory care
Studies of preventive and ambulatory care use by patient race reveal mixed findings. For some services—e.g., colorectal cancer screening, lipid lowering therapy—racial disparities do not appear prevalent.55–58
Studies did reveal disparities in some primary care outcome measures, including achieving blood pressure and lipid goals, but these findings may have been explained in part by more severe disease among non-whites.59,60
Non-whites with hypertension were less adherent to medications, both unintentionally and intentionally, part of which was related to medication side effects.60,61
Qualitative research suggested that disparities in cardiovascular risk management may be related to low health literacy, less knowledge, and less assertiveness with physicians among African-American patients.62
African Americans were less likely than whites to receive influenza vaccines. In addition, both African Americans and Latinos were less likely than whites to know they needed a vaccination and more likely to rely on physician recommendations and reminders to receive vaccinations.63
Sources of Disparities
Several themes emerged from our qualitative review as likely contributors to racial disparities in VA health care.
- Patient medical knowledge and information sources. Non-white and white patients differ in their familiarity with and knowledge about medical interventions. This difference stems from different levels of experience with those interventions among minority versus white patients and their families, friends, and communities; from different amounts of information conveyed by health care providers; and from different levels of health literacy and understanding among patients. Different knowledge and information may affect patients’ perceptions of, or degree of uncertainty about, the necessity and benefits of medical interventions in relation to their risks. Uncertainty about the necessity of interventions may in turn reduce patients’ willingness to accept and adhere to them. Several studies indicate that minority patients are less informed about their care and that this difference affects decision making.20,21,48,62–65
- Patient trust and skepticism. Minority patients also harbor less trust and more skepticism about medical interventions. These perceptions appear to be influenced by lack of familiarity with medical interventions (described above), by historical or personally experienced discrimination, and for some African-American patients in particular, by a reliance on religious and spiritual avenues, as opposed to medical therapies, for coping with illness. Studies in our review suggest that minority patients are also more skeptical than whites of information provided by health care professionals.20,41,44,47,49
- Patient participation. Several studies suggest that non-white patients are less active participants in their care as compared to white patients.21,22,48,53,62 Non-white patients tend to ask fewer questions of their providers, who in turn provide less information. Less information may lead to lower acceptance of and adherence to medical interventions. In addition, lower patient participation diminishes the strength of the patient–provider partnership, which may lead to less investment by both parties in following recommended care plans, and to lower trust and greater skepticism among minority patients.
- Patient social support and resources. Non-white patients may have less social support and fewer external resources to help with both illness management and decision making. This is particularly relevant in that minority patients may rely more heavily on external resources than on health care professionals for information and support. This may particularly affect adherence and decision making around high-risk procedures.66
- Clinician judgment. Studies suggest that clinicians’ diagnostic and therapeutic decision making varies by patient race. The degree to which this differential decision making is based on clinical factors versus non-clinical factors, including racial stereotypes, is unclear. For instance, in 1 study clinicians judged African-American patients to be less appropriate candidates for coronary interventions, even after accounting for chart-documented variables.41 The degree to which this difference was driven by unmeasured clinical factors, by the influence of patient preferences on physician decision making, or by physician bias, was not determined. Similarly, clinicians prescribe opioid medications less frequently to African-American versus white patients6 and are more likely to diagnose African-American patients presenting with mental illness as having psychotic versus affective disorders.51,52 The degree to which these phenomena are driven by racial differences in coexisting substance abuse disorders, by cross-cultural misunderstanding of symptom presentations, or by racial bias, remains unclear. The presence of racial bias was suggested by the finding in 1 study that physicians were more likely to write do-not-resuscitate orders based on medical futility among non-white compared to white patients, independent of the same physicians’ predictions of the likelihood that the patients would survive resuscitation efforts.67
- Racial/cultural milieu. Some have suggested that a more racially and culturally congruent health care environment (including racially concordant health care providers) for minority patients may elevate trust, reduce skepticism, and enhance the acceptability of care. Two studies directly examined this issue and found that African-American patients experienced better interactions and fared somewhat better clinically, when cared for by African-American versus white providers.48,53 Another study suggested that African-American patients in group therapy might fare better when grouped with other African-American patients.54
- Healthcare facility characteristics. Some disparities are at least partly explained by the fact that minority and white patients tend to receive care at different medical centers.42,68–70 In some cases, centers that disproportionately serve minority patients have fewer available services or deliver lower quality care overall than centers serving predominantly white patients. This potential source of disparities, however, remains underexplored. It should be noted that many studies have demonstrated disparities within single centers, suggesting that system-level factors are unlikely to explain all observed disparities.