1) How do individual physicians contribute to health care disparities? Thinking about an area of health care of particular interest to you, what research do you think could be done to either understand the effect of individual physicians on health disparities, or to decrease this effect?
An area of health care that is of particular interest to me is radiology, so this week I was very interested to read about a study published in 2013 entitled "Racial Disparities in Ordering Laboratory and Radiology Tests for Pediatric Patients in the Emergency Department." It was a retrospective case cohort study that examined cases from two community emergency departments (ED) that served urban populations. Both EDs had access to on-site laboratory and radiological services 24 hours a day. The researchers found that Native American, biracial, Hispanic, and African American racial categories were associated with a lower adjusted odds ratio of getting laboratory and radiological testing compared with non-Hispanic whites. The analysis had been done on subgroups of patients with the same ICD diagnosis and distance traveled to present to the ED. Interestingly, speaking a non-English language at home was associated with an increase in laboratory and radiological testing, with the exception of Spanish: speaking Spanish at home was associated with decreased odds of radiological testing. The authors pointed out that there were several factors that could have contributed to these results, such as physicians' not wanting to repeat previously normal test results if a patient visited the ED frequently, which in turn was likely related to the patients' socioeconomic status and poor access to primary care. All in all, individual physicians may contribute to health care disparities by making ordering decisions that are influenced in part by unconscious racial biases. A final fascinating and promising finding of this study was that for the diagnosis of pediatric head injury, a problem almost always evaluated using a specific algorithm, no racial disparity was found. Future studies may examine whether other medical conditions that utilize well-defined algorithms are similarly found to not face racial disparities when it came to patients' getting accurate and timely diagnoses. Algorithms, if developed and used properly, could be one promising solution to mitigating unconscious racial bias from individual physicians.
2) Structural issues within health care delivery are implicated in health care disparities. Please brainstorm 4 structural issues that might contribute to these disparities. Which of these are relevant to your particular area of research, and how?
Four structural issues that contribute to health care disparities include: 1) poor primary care access, 2) lack of cultural competency infractures, e.g. having adequate translation services in acute settings such as the ED, 3) lack of diversity among health care providers, particularly those in leadership positions 4) racial and ethnic discrimination (as faced in life in the U.S. in general, not only in a health care setting). These structural issues can contribute to the disparities in radiological care. When patients have poor access to primary care such as due to a lack of health insurance affordability, they may have to present to the ED more frequently, which can have a confusing impact on how physicians chose to order workup including medical imaging. If a patient presented a week ago, had a normal CT, and presented for a similar complaint again this week, the physician may be reluctant to repeat the same imaging. If the patient had access to regular primary care that focused on preventative care, they would likely have a different experience with the type of workup they received and better health overall. Furthermore, lack of diversity among health care providers may contribute to unconscious racial biases' influencing patient care. Those in leadership positions have a responsibility to provide bias training (there is controversy over how effective this is; more efforts should be made to improve its efficacy) as well as to hire diverse providers who can adequately address the nuanced needs of a diverse patient population.
Reference:
Nathaniel R Payne, Susan E Puumala. "Racial Disparities in Ordering Laboratory and Radiology Tests for Pediatric Patients in the Emergency Department." Pediatr Emerg Care, 29 (5), 598-606, May 2013.