Health Disparities Based on Race or Ethnicity Require Interventions at Multiple Levels of the Healthcare System

Abstract

Health disparities have been defined by the Institute of Medicine (IOM) as “differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention” [1]. The World Health Organization (WHO) describe health inequities as “differences in health status, or in the distribution of health resources between different population groups, arising from the social conditions in which people are born, grow, live, work, and age” [2]. The WHO emphasizes that health inequities are a global issue which is “unfair and could be reduced by the right mix of government policies” [2]. Health disparities often lead to negative health outcomes such as increased morbidity and disability, higher mortality rates and reduced quality of life for groups that experience reduced quality of healthcare and treatment. In 2000, the Department of Health and Human Services launched a comprehensive nationwide, health promotion and disease prevention agenda in the United States [3]. The report called for the elimination of all health disparities, including differences that occur due to ethnicity, sex, education, income, disability, geographic location, or sexual orientation. The Institute of Medicine published a report in 2003 entitled Unequal treatment: confronting racial and ethnic disparities in healthcare [1].

Hall-Lipsy and Chisholm-Burns carried out a systematic review of “pharmacotherapeutic disparities” in medication treatment [4]. A total of 311 research articles were identified that investigated whether race, ethnicity, or sex was associated with disparities in medication treatment. Seventy-seven percent of the included articles revealed significant disparities in drug treatment across race, ethnicity, and sex. The most frequent disparity found in almost three-quarters of the articles studied was differences in the receipt of prescription drugs. Documented disparities also occurred related to differences in the drugs prescribed, drug dosing administration, and wait time to receipt of a drug. Documented outcomes associated with these disparities included increased rates of hospitalization, decreased rates of therapeutic goal attainment, and decreased rates of survival. Clinical content areas included treatment for asthma, cardiovascular disease, diabetes mellitus, HIV infection, mental health, oncology, osteoporosis, pain control/palliative care, and Parkinson's disease. The top three in terms of number of publications were mental health, cardiovascular disease, and pain control/palliative care.

In this edition of the Journal of the American Geriatrics Society (JAGS), Cassara et al. report on a study related to the use and discontinuation rates of long-acting injectable (LAI) antipsychotic medications among older adults, with a focus on differences based on race/ethnicity [5]. The authors utilized Medicaid databases to identify older adults diagnosed with schizophrenia, schizotypal, or schizoaffective disorders. More than 500 individuals with an average age of 70.4 years met inclusion for analysis. The study found disparities in the prescribing of LAI antipsychotics between Black and White populations. Although second-generation antipsychotics are generally recommended as being optimal versus first-generation antipsychotics, especially for older adults, the study suggests Black patients receive first-generation LAI antipsychotics significantly more often than White patients. This is a particular concern because older adults are at a higher risk of the adverse effects of antipsychotics, including the development of movement disorders. The study also found that discontinuation rates were significantly higher for first-generation antipsychotics compared to second-generation antipsychotics. The authors note that adverse effects most prominent with first-generation antipsychotics include neuromotor problems such as parkinsonism and tardive dyskinesia, anticholinergic and autonomic adverse effects, and sexual dysfunction. Older adults are also more likely to experience polypharmacy that can contribute to negative outcomes such as drug–drug interactions and more severe adverse effects, which may lead to earlier discontinuation. The authors also describe evidence that prescriber ethnic bias may be present in the prescribing and perceived effectiveness of first- versus second-generation antipsychotics. The study does have some limitations, as noted by the authors. They report that patient diagnoses were collected using ICD-10 billing codes in which neither the validity nor severity of schizophrenia is properly defined. Another limitation may be the self-reported identification of race/ethnicity that is common among large data claims. They also note that retrospective study data preclude understanding the reasons for treatment discontinuation. The authors also mention that exclusion criteria included older adults with a diagnosis of Alzheimer's disease or other dementias. They suggest further studies are needed to assess the presence of racial disparities and accessibility of LAI second-generation antipsychotics for Black people. Another recent example of racial disparities in prescribing psychotropic medications among older adults is a study of U.S. veterans. Among patients with severe depression, for whom prescription of antidepressants was clinically indicated, White patients were 1.87 times more likely than Black patients to receive an antidepressant prescription [6].

The 2003 IOM Report on health disparities provided a summary of key findings, which remain highly relevant today [1]. The report emphasizes that racial and ethnic disparities in healthcare exist, are associated with worse outcomes, and concludes that they are “unacceptable.” The report notes that racial and ethnic disparities in healthcare occur in the context of broader historic and contemporary social and economic inequality and evidence of persistent racial and ethnic discrimination in many sectors of American life. The report also suggests that health systems, healthcare providers, patients, and utilization managers may all contribute to racial and ethnic disparities in healthcare. Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to these disparities. The report notes that while indirect evidence from several lines of research supports the latter statement, a greater understanding of the prevalence and influence of these processes is needed and should be sought through research. The IOM report includes a series of recommendations, which include promoting increased awareness of racial and ethnic disparities in healthcare. Recommended interventions are subsequently grouped into the following categories: legal, regulatory, and policy; health systems; patient education and empowerment; cross-cultural education in the health professions; data collection and monitoring; and research needs [1]. The later includes a focus on promising interventions, ethical issues, and barriers to eliminating disparities.

Lundebjerg and Medina-Walpole described the commitment of the American Geriatrics Society (AGS) to take purposeful steps to address racism in health care, given its impact on older adults, their families, and communities [7]. They highlight the commendable AGS 2020 statement, which was added to its vision for the future. The statement is as follows: “We all are supported by and able to contribute to communities where ageism, ableism, classism, homophobia, racism, sexism, xenophobia, and other forms of bias and discrimination no longer impact healthcare access, quality, and outcomes for older adults and their caregivers.” The paper included concrete steps to address this critical issue.

Farrell et al. noted in JAGS that the intersection of structural racism and ageism compounds the disadvantage experienced by historically marginalized communities [8]. The authors explain that the constructs of racism and ageism can have negative effects on health outcomes that can be magnified when race and age intersect. The authors emphasize that the AGS is working to identify and dismantle the healthcare structures that create and perpetuate these combined injustices and, in so doing, create a more just U.S. healthcare system. They suggest that three fundamental changes are required to create a just healthcare system. First, the healthcare workforce must both reflect and be better prepared to care for the populations that it serves. Second, how we train and support the next generation of health professionals must change so that we are truly supporting trainees from diverse backgrounds to achieve success in their chosen careers. Third, all aspects of healthcare must be examined from the perspective of the intersection of ageism, not only with racism, but also with other biases (e.g., ableism, sexism, homophobia, xenophobia). Rhodes et al. in a 2022 JAGS editorial describe the ambitious efforts by this journal to enhance diversity, equity, and inclusion [9]. Hopefully, the excellent goals described in this paragraph will have positive long-lasting effects throughout the healthcare system and will be emulated in the many other countries facing similar challenges.

David Conn was a reviewer for the original paper by Cassara et al. and wrote this editorial.

The author declares no conflicts of interest.

This publication is linked to a related article by Cassara et al. To view this article, visit https://doi.org/10.1111/jgs.19386.