There is inconclusive evidence to support that race-concordance is associated with desirable outcomes for minorities. Only nine of the 27 studies reviewed found support for race-concordance. Even among these, some found only modest effect of race-concordance on outcomes (Lasser et al. 2005
) and others (Saha et al. 2000
, LaVeist and Carroll 2002
, LaVeist and Nuru-Jeter 2002
) were conducted using a single data source and did not have mutually exclusive respondent groups and outcomes. Notwithstanding the limitations of the body of literature and current analysis, the predominant finding in the category of healthcare provision suggests that having a provider of the same race does not particularly improve receipt of services for minorities. The studies under healthcare provision were heterogeneous with regard to outcomes and methods. Further, about half of the studies in both ‘provision’ and ‘utilization’ categories were based on patients’ self-report. While self-report is appropriate for some outcomes, such as patients’ preference and satisfaction, it may not be reliable for some other outcomes. Studies comparing agreement between self-report versus medical records for healthcare provision and utilization have found that reports of under or over utilization occur by individuals’ health status (Glandon et al. 1992
), type of service (Glandon et al. 1992
; Lubeck and Hubert 2005
), and frequency of service used (Glandon et al. 1992
). A recent study of health service utilization among marginalized population found poor agreement for ambulatory visits and laboratory tests performed and poor to fair agreement for medication use (Cunningham et al. 2007
). Future studies may appropriately use an objective measure of health provision and utilization.
Interestingly, there are inconclusive results in minority patients’ preference, satisfaction, and communication domains. While there were only a small number of studies in each of these categories, studies of mixed findings raise concerns about either lack of power to detect true effect of race-concordance or true heterogeneity in the effect of race-concordance among subsets of minorities. For instance, the literature indicating mixed findings in the preference for racial/ethnic concordance may present a scenario where racial/ethnic alliance may be important only to a segment of population, possibly reflecting intra-group diversity in their expectations of healthcare providers and the treatments that they prescribe.
In some studies, race-concordance was associated with minority patients’ outcomes in combination with other factors such as language, length of patient–provider relationship or site of care. These findings suggest that race-concordance may be a heterogeneous construct and may stand as a proxy for a more complex dynamic embodying a combination of many patient, provider and system variables. This view of concordance allows future studies to carefully consider interactions of race-concordance with other patient, provider and setting-level variables critical to a more nuanced examination of this concept.
A number of factors ought to be considered in evaluating the relevance of the concept of patient–provider race-concordance within the US healthcare context. First, the issue of race/ethnicity is complex on several levels, and the existing research does not appear to capture these complexities. Invariably, the studies were limited to only four racial/ethnic groups: Whites, Blacks, Hispanics and Asians, with Whites and Blacks representing over two-thirds of the patient and provider samples. The US Census Bureau collects data on six racial categories including: (1) White; (2) Black or African American; (3) American Indian/Alaska Native; (4) Asian; (5) Native Hawaiian/Pacific Islander; and (6) Some other race (US Census Bureau 2001
). ‘Race’ and ‘Hispanic origin’ represent two separate concepts, as Hispanics may belong to any of the six racial categories or to multiple races (US Census Bureau 2000
). This distinction was missing in a number of studies analyzed.
In the last US Census held in 2000, the Census Bureau, for the first time, permitted marking of ‘more than one race’ to capture an increasing number of people who identify themselves as multiracial: 6.8 million people identified themselves as belonging to more than one race; of these, 11.5% were both White and Black, 12.7% were both White and Asian, and 32.3% reported being White and ‘Some other race’ (US Census Bureau 2001
). Sixty-three possible race combinations exist for the six basic racial categories and 57 categories for those who report two or more races (US Census Bureau 2000
). Thus, it is not clear how the racial/ethnic concordance literature may relate to minorities who are biracial or multiracial.
Finally, the underlying assumption of the racial/ethnic concordance literature is that patients and providers are able to identify with people of similar race/ethnicity who may look like them or share similar language or culture. This approach undermines the vast heterogeneity that exists within some racial groups. For instance, the ‘Asian’ category in the US census includes subcategories ranging from Koreans to Asian Indians. These so-called ‘Asian’ subcultures are as removed from each other as any other major racial groups, thus raising a question about the relevance of the concept of concordance to the subsets of minorities.
Further, the race-concordance literature should also be evaluated in the light of limitations pertaining to minority providers. First, a majority of the studies in this review was conducted with the physician
providers, thus limiting understanding of the implications of race-concordance concept for other health providers, for example, nurse practitioners, who increasingly manage patients in a variety of healthcare settings. Further, about half the studies did not include a provider sample as they relied on patients’ self-report and perceptions about providers of same versus different race/ethnicity. Even among the studies that included a provider sample, minority providers were particularly low, possibly due to the serious shortage of minority health providers in the US health system. While Hispanics, non-Hispanic African Americans and American Indians represent over 27% of the US population (US Census Bureau 2007
), less than 9% of nurses, 6% of physicians, and 5% of dentists are from these racial/ethnic groups (Sullivan 2004
). The level of minorities in the workplace is expected to decrease due to the low levels of underrepresented minorities enrolled in health professional schools (Sullivan 2004
The issue of newly migrant health professionals further complicates the issue of race-concordance. The American Association of Medical Colleges estimate that 5% of immigrants have entered medical schools and a majority of these physicians will remain in the USA permanently after graduation (AAMC 2005
). About 14% of nurses and 20% of physicians in the USA are from foreign countries (Brush et al. 2004
, AAMC 2005
). It is expected that with the current workforce shortage, the majority of current vacancies are more likely be filled by foreign nurses and physicians. This introduces the issue of generational congruence in the debate of racial/ethnic concordance. For instance, would the race-concordance concept be relevant for patients and providers with racial concordance but generational discordance and differences in the levels of acculturations?
On a normative level, the problem with the concept of race-concordance is that it can potentially create a perception that only the providers of same race or ethnicity are best suited to provide appropriate or effective healthcare. Race is, after all, a social construct. Focusing on race-concordance could potentially create a racially segregated healthcare system and may perpetuate stereotypes and generalizations about how certain minority groups ought to be treated. Thus, it is imperative that the findings of race-concordance literature and future efforts be examined in the light of the above normative risks including a racially segregated health delivery system. It may be argued that increasing diversity in the healthcare professions is a laudable goal and should be pursued regardless of the tangible ends it may serve.
The authors are unaware of any prior comprehensive reviews on this topic. Nevertheless, this review has several limitations. The data analysis was limited to tabular and text format due to heterogeneity in methods and outcomes between studies as well as smaller numbers of studies within each outcome category. A meta-analysis may be conducted as data accumulates on the topic. Because this review was limited to tabular and descriptive analysis, qualitative studies were not excluded. Due to the nature of qualitative research, these studies typically had small sample sizes. Thus, median sample and range are reported for the pooled sample for each minority group. Future studies undertaking a meta-analysis may appropriately exclude qualitative studies or use synthesis technique appropriate to qualitative data. While two authors independently categorized studies and compared findings, the results of this review may be confounded by how studies were assigned to individual outcome category. Finally, this analysis included only published studies.
Many gaps remain in our understanding of if, why, and how patient–provider race-concordance may influence minority patients’ outcomes, what health outcomes may be more sensitive to cultural proximity between patients and providers, and what patient, provider and setting-level variables may mediate or moderate these outcomes? These questions can guide researchers whose goals are to understand and dismantle health inequalities among many racial/ethnic minority populations. There is also a need to evaluate the concept of race-concordance while considering the limitations of this body of research, normative risks, and practical realities of the minority workforce in the US health care system.