Clinicians’ Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients

PURPOSE

We investigated whether clinicians’ explicit and implicit ethnic/racial bias is related to black and Latino patients’ perceptions of their care in established clinical relationships.

METHODS

We administered a telephone survey to 2,908 patients, stratified by ethnicity/race, and randomly selected from the patient panels of 134 clinicians who had previously completed tests of explicit and implicit ethnic/racial bias. Patients completed the Primary Care Assessment Survey, which addressed their clinicians’ interpersonal treatment, communication, trust, and contextual knowledge. We created a composite measure of patient-centered care from the 4 subscales.

RESULTS

Levels of explicit bias were low among clinicians and unrelated to patients’ perceptions. Levels of implicit bias varied among clinicians, and those with greater implicit bias were rated lower in patient-centered care by their black patients as compared with a reference group of white patients (P = .04). Latino patients gave the clinicians lower ratings than did other groups (P <.0001), and this did not depend on the clinicians’ implicit bias (P = .98).

CONCLUSIONS

This is among the first studies to investigate clinicians’ implicit bias and communication processes in ongoing clinical relationships. Our findings suggest that clinicians’ implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes. As such, this finding supports the Institute of Medicine’s suggestion that clinician bias may contribute to health disparities. Latinos’ overall greater concerns about their clinicians appear to be based on aspects of care other than clinician bias.Key words: race, ethnicity, communication, prejudice, patient-centered care, healthcare disparities, primary care, practice-based research     

Racial and Ethnic Disparities and Perceptions of Health Care: Does Health Plan Type Matter?

OBJECTIVE: To examine whether racial and ethnic differences in the distribution of individuals across types of health plans explain differences in satisfaction and trust with their physicians. DATA SOURCES: Data were derived from the 1998-1999 Community Tracking Household and Followback Studies and consisted of a nationwide sample of adults (18 years and older). DATA COLLECTION: The data were collected by telephone survey. Surveys were administered in English and Spanish. The response rate for the Household Survey was 63 percent, and the match rate for the Followback Survey was 59 percent. STUDY DESIGN: Multivariate analyses used regression methods to detect independent effects of respondent race and ethnicity on satisfaction and trust with physician, while controlling for enrollment in different types of health plans. PRINCIPAL FINDINGS: Racial and ethnic minorities are more likely than whites to have lower levels of trust and satisfaction with their physician. The most prominent differences occurred within the Latino and Native American/Asian American/Pacific Islander/Other ("Other") populations. Plan type does not mitigate the relationship between race/ethnicity and trust and satisfaction for the overall adult population. CONCLUSIONS: Disparate levels of trust and satisfaction exist within ethnic and minority populations, even when controlling for the distribution of individuals across types of health plans. The results demonstrate a need to better understand the health care-related factors that drive disparate trust and satisfaction.     

Sex and Racial/Ethnic Differences in Premature Mortality Due to HIV: Florida, 2000–2009

Objective

This study aimed to characterize premature mortality among people diagnosed with HIV infection from 2000 to 2009 in Florida, by sex and race/ethnicity, to estimate differences in premature mortality that could be prevented by linkage to HIV care and treatment.

Methods

Florida surveillance data for HIV diagnoses (excluding concurrent AIDS diagnoses) were linked with vital records data to ascertain deaths through 2011. Years of potential life lost (YPLL) were obtained from the expected number of remaining years of life at a given age from the U.S. sex-specific period life tables.

Results

Among 41,565 people diagnosed with HIV infection during the study period, 5,249 died, and 2,563 (48.8%) deaths were due to HIV/AIDS. Age-standardized YPLL (aYPLL) due to HIV/AIDS per 1,000 person-years was significantly higher for females than males (372.6, 95% confidence interval [CI] 349.8, 396.2 vs. 295.2, 95% CI 278.4, 312.5); for non-Hispanic black (NHB) females than non-Hispanic white (NHW) and Hispanic females (388.2, 95% CI 360.7, 416.9; 294.3, 95% CI 239.8, 354.9; and 295.0, 95% CI 242.9, 352.5, respectively); and for NHB males compared with NHW and Hispanic males (378.7, 95% CI 353.7, 404.7; 210.6, 95% CI 174.3, 250.8; and 240.9, 95% CI 204.8, 280.2, respectively). In multilevel modeling controlling for individual factors, NHB race was associated with YPLL due to HIV/AIDS for women (p=0.04) and men (p<0.001).

Conclusion

Among people diagnosed with HIV infection, females and NHB people had a disproportionately high premature mortality from HIV/AIDS, suggesting the need for enhanced efforts to improve linkage to and retention in care and medication adherence for these groups.Minority groups in the United States are disproportionately affected by human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). In 2009, the estimated annual HIV incidence rate was 7.7 times higher for non-Hispanic black (NHB) people and 2.6 times higher for Hispanic people than for non-Hispanic white (NHW) people (69.9, 26.4, and 9.1 per 100,000 population, respectively).¹ These racial/ethnic disparities persist in HIV mortality rates. In 2010, the age-adjusted HIV mortality rate among NHB people was 7.2 times greater for men (16.5 vs. 2.3 per 100,000 population) and 15.0 times greater for women (7.5 vs. 0.5 per 100,000 population) than among NHW people.²In the era of antiretroviral therapy (ART), the life span among people living with HIV who are appropriately treated is approaching that of underlying populations.^3,4 As people living with HIV live longer, they are more likely to die from non-HIV causes such as heart disease, liver disease, and cancer.^5–7 Numerous studies have documented a declining proportion of deaths due to AIDS, particularly for those in care.^8–10 However, the benefits of ART have not been fully realized for the majority of people living with HIV. To benefit from these treatment advances, individuals must be diagnosed early in the course of their illness, be linked to care, be offered treatment, and adhere to treatment. Nationally, people are being lost at each step of this continuum. It is estimated that in 2009, 66% of people diagnosed with HIV were linked to care, 37% were retained in care, 33% were prescribed ART, and 25% had a suppressed viral load. Relative to NHW people, NHB people (and, to a lesser extent, Hispanic people) had lower percentages at each step of the care continuum. In 2009, an estimated 79% of NHB, 74% of Hispanic, and 70% of NHW people with HIV infection had no viral load suppression.¹¹HIV is a burden for communities because it tends to cause death at younger ages than more common causes of death (e.g., cancer and heart disease). Comparing the impact of HIV using mortality rates alone does not capture the impact of premature mortality. However, years of potential life lost (YPLL), which measures premature mortality, tallies the number of years a person would have been expected to live had he/she not died early.¹² The objective of this study was to characterize premature mortality among people diagnosed with HIV from 2000 to 2009 in Florida, by sex and racial/ethnic group, to estimate differences in premature mortality that could be prevented by linkage to HIV care and treatment.     

Geographic Poverty and Racial/Ethnic Disparities in Cervical Cancer Precursor Rates in Connecticut, 2008–2009

Objectives. We examined associations of geographic measures of poverty, race, ethnicity, and city status with rates of cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ (CIN2+/AIS), known precursors to cervical cancer.Methods. We identified 3937 cases of CIN2+/AIS among women aged 20 to 39 years in statewide surveillance data from Connecticut for 2008 to 2009. We geocoded cases to census tracts and used census data to calculate overall and age-specific rates. Poisson regression determined whether rates differed by geographic measures.Results. The average annual rate of CIN2+/AIS was 417.6 per 100 000 women. Overall, higher rates of CIN2+/AIS were associated with higher levels of poverty and higher proportions of Black residents. Poverty was the strongest and most consistently associated measure. However, among women aged 20 to 24 years, we observed inverse associations between poverty and CIN2+/AIS rates.Conclusions. Disparities in cervical cancer precursors exist for poverty and race, but these effects are age dependent. This information is necessary to monitor human papillomavirus vaccine impact and target vaccination strategies.Genital human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with an estimated 6.2 million adolescents and young adults newly infected every year.1 The prevalence of infection ranges from 27% to 45% among young women, and nearly 40% of women acquire HPV within 2 years of initiating sexual activity.2–4 HPV is also an important public health problem because persistent infection with a high-risk HPV type is a necessary cause of cervical cancer.5–7 Women living in poverty and racial/ethnic minorities continue to bear a disproportionate burden of cervical cancer incidence and mortality despite the decrease in rates that has resulted from widespread cervical cancer screening.8,9 In 1998 to 2003, US incidence rates of invasive cervical cancer were 12.6 per 100 000 among Black women, 14.2 among Hispanics, and 8.4 among Whites; mortality rates showed similar disparities.10 This pattern continued through 2007.11 In a study from Massachusetts and Rhode Island, incidence rates in areas with 20% or higher and less than 5% of the population living in poverty were 17.6 and 9.2 per 100 000, respectively.12 Data from a study in New York City revealed neighborhood poverty to be an important predictor of cervical cancer mortality.13Precursors to cervical cancer are cervical intraepithelial neoplasia grades 2, 2/3, and 3 (CIN2+) and adenocarcinoma in situ (AIS). CIN2+/AIS diagnoses are an important public health problem not only because they are precursors to invasive disease, but also because they are common diagnoses that impose substantial health care costs and patient burden. Approximately 500 000 women are diagnosed each year with high-grade cervical disease, and these diagnoses account for annual health care costs of $450 million.14–16 At the individual level, a diagnosis of CIN2+ results in an average of 7 to 8 office visits and 20 months of follow-up.16 Many women also experience adverse psychological consequences following a diagnosis, such as fear of cancer, anxiety, distress, and concern about future fertility, along with medical procedures and difficulties with sexual relationships.17 Disparities in precancerous lesions have not been directly examined, to the best of our knowledge. Data from 2 studies reveal noticeably higher rates of precancerous lesions among low-income women in a national screening program (4.6–7.4/1000 women) than among health plan enrollees (1.5/1000), who were likely of higher socioeconomic status18,19; however this is not a direct or precise comparison.Since 2006, the Food and Drug Administration has approved 2 HPV vaccines that protect against 2 high-risk HPV types (HPV 16/18), which cause approximately 70% of cervical cancers. These vaccines have proven efficacy of 95% or higher in protecting against HPV 16/18–associated cervical lesions in HPV-naive women.20,21 The Advisory Committee on Immunization Practices recommends routine use of either vaccine in a 3-dose regimen for girls aged 11 or 12 years and catch-up vaccination through age 26 years.22 These vaccines have the potential to reduce disparities in cervical cancer. However, the extent to which this is realized will depend on high vaccine coverage for populations at greatest risk for outcomes associated with HPV infection. If vaccine coverage is not adequate and targeted, current disparities in cervical cancer may widen rather than narrow.HPV vaccination programs may affect cervical cancer precursors and associated procedures within years rather than the decades it will take to measure impact on cervical cancer.21,23–26 Therefore, determining the burden of cervical cancer precursors should be a public health priority because this information can be used to target vaccination strategies and provide a baseline for monitoring vaccine impact and disparities over time. We examined disparities in CIN2+/AIS rates in Connecticut, a state with mandatory reporting of these conditions, during prevaccine impact years 2008 to 2009, by geographic sociodemographic measures of poverty, race, ethnicity, and city status. We chose the first 3 measures because they are the most commonly used indicators of disparities in cervical cancer.8,10,12,13 We included a city measure because we hypothesized that disparities may exist along an urban gradient. Our results fill a key knowledge gap because few states mandate CIN2+/AIS reporting, and no statewide analysis of cervical cancer precursors and geographic measures has been reported.     

Does the Market Value Racial and Ethnic Concordance in Physician–Patient Relationships?

OBJECTIVE: To determine if the market-determined earnings per hour of physicians is sensitive to the degree of area-level racial/ethnic concordance (ALREC) in the local physician labor market. DATA SOURCES: 1998-1999 and 2000-2001 Community Tracking Study Physician Surveys and Household Surveys, 2000 U.S. Census, and the Area Resource File. STUDY DESIGN: Population-averaged regression models with area-level fixed effects were used to estimate the determinants of log earnings per hour for physicians in a two-period panel (N=12,886). ALREC for a given racial/ethnic group is measured as the percentage of physicians who are of a given race/ethnicity less the percentage of the population who are of the corresponding race/ethnicity. Relevant control variables were included. PRINCIPAL FINDINGS: Average earnings per hour for Hispanic and Asian physicians varies with the degree of ALREC that corresponds to a physician's race/ethnicity. Both Hispanic and Asian physicians earn more per hour in areas where corresponding ALREC is negative, other things equal. ALREC varies from negative to positive for all groups. ALREC for Hispanics is negative, on average, due to the small percentage of the physician workforce that is Hispanic. This results in an average 5.6 percent earnings-per-hour premium for Hispanic physicians. However, ALREC for Asians is positive, on average, due to the large percentage of the physician workforce that is Asian. This results in an average 4.0 percent earnings-per-hour discount for Asian physicians. No similar statistically significant results were found for black physicians. CONCLUSIONS: The market-determined earnings per hour of Hispanic and Asian physicians are sensitive to the degree of ALREC in the local labor market. Larger sample sizes may be needed to find statistically significant results for black physicians.     

Racial and Ethnic Disparities in the Continuation of Community-Based Children’s Mental Health Services

This paper examines racial and ethnic disparities in continuation of mental health services for children and youth in California and how English language proficiency moderates the effect of race/ethnicity on the continuation of service. While previous research indicated racial/ethnic or geographic disparities in accessing mental health services among children and youth, few studies specifically focused on the continuation of mental health care. The authors used administrative data from California county mental health services users under age 25. Applying logistic regression, English language proficiency was found to be the major determinant of continuation of mental health services in this age group. With the exception of children of Asian descent, non-English speaking children and youth of diverse racial/ethnic background were significantly less likely to continue receiving mental health services compared with White English-speaking peers, even after controlling for sociodemographic, clinical and county characteristics.     

Explaining Racial/Ethnic Disparities in Children’s Dental Health: A Decomposition Analysis

Objectives. We measured racial/ethnic inequalities in US children’s dental health and quantified the contribution of conceptually relevant factors.Methods. Using data from the 2007 National Survey of Children’s Health, we investigated racial/ethnic disparities in selected child dental health and preventive care outcomes. We employed a decomposition model to quantify demographic, socioeconomic, maternal health, health insurance, neighborhood, and geographic effects.Results. Hispanic children had the poorest dental health and lowest preventive dental care utilization, followed by Black then White children. The model explanatory variables accounted for 58% to 77% of the disparities in dental health and 89% to 100% of the disparities in preventive dental care. Socioeconomic status accounted for 71% of the gap in preventive dental care between Black children and White children and 55% of that between Hispanic children and White children. Maternal health, age, and marital status; neighborhood safety and social capital; and state of residence were relevant factors.Conclusions. Reducing US children’s racial/ethnic dental health disparities—which are mostly socioeconomically driven—requires policies that recognize the multilevel pathways underlying them and the need for household- and neighborhood-level interventions.Race/ethnicity is a significant determinant of dental health in different countries, and racial/ethnic minority status is a well-known risk factor for poor dental health.1,2 Racial/ethnic differences in children’s dental health are common in the United States. Among children aged 2 to 11 years, Black children and Hispanic children are more likely to have decayed teeth and untreated dental problems than are White children.3,4 The rate of primary dentition caries in 1999 through 2004 was 55.0% for Hispanic children, 43.0% for Black children, and 39.0% for White children.3 About 6.5% of non-Hispanic White children have fair or poor oral health, compared with 12.0% of Black children and 23.4% of Hispanic children, with large racial/ethnic differences remaining after adjusting for age, gender, education, poverty level, dental insurance, and parental preventive care attitude.5Racial/ethnic disparities also exist in children’s access to dental care in the United States. Larger unmet dental care needs are observed in non-White children. Moreover, Hispanic children have the highest likelihood of never having seen a dentist.6,7 In addition, among children who are publicly insured through Medicaid and the State Children’s Health Insurance Program, Hispanics and Blacks have longer intervals between dental visits and higher tooth decay rates.8Although documenting racial/ethnic disparities in child dental health is important, of greater relevance is identifying the pathways that explain these inequalities to inform policies that can effectively reduce them. Although racial/ethnic disparities in child dental health have been well documented, few studies have explored their underlying pathways, and none has formally quantified the contributions of socioeconomic, demographic, and neighborhood characteristics to these disparities. Previous studies highlight some factors as relevant for racial/ethnic disparities, including socioeconomic condition, health literacy, educational attainment, dental insurance, language barriers, and cultural characteristics.2,9–11 However, these studies did not adequately characterize the individual contributions of these and other theoretically relevant factors to disparities. To fill this research gap, we measured racial/ethnic inequalities in child dental health in a nationally representative sample, and, with a decomposition analysis, we quantified the extent to which the observed disparities are attributable to conceptually relevant factors. In doing so, we have highlighted important pathways contributing to child dental health disparities.     

Individual,Family Background,and Contextual Explanations of Racial and Ethnic Disparities in Youths’ Exposure to Violence

We used data from the Project on Human Development in Chicago Neighborhoods to examine the extent to which individual, family, and contextual factors account for the differential exposure to violence associated with race/ethnicity among youths. Logistic hierarchical item response models on 2344 individuals nested within 80 neighborhoods revealed that the odds of being exposed to violence were 74% and 112% higher for Hispanics and Blacks, respectively, than for Whites. Appreciable portions of the Hispanic–White gap (33%) and the Black–White gap (53%) were accounted for by family background factors, individual differences, and neighborhood factors. The findings imply that programs aimed at addressing the risk factors for exposure to violence and alleviating the effects of exposure to violence may decrease racial/ethnic disparities in exposure to violence and its consequences.Homicide is a leading cause of death among young Americans, accounting for 14.8% of deaths among persons aged 10 to 24 years.1 Yet homicide reflects only a small portion of adolescent violence. Estimates indicate that the ratio of nonfatal to fatal assaults is as high as 100 to 1,2 and studies have found that between 50% and 96% of urban youths have witnessed some form of community violence (e.g., seeing a shooting or assault, hearing a gunshot) in their lifetime.3–6 The rate of secondary exposure to community violence is of particular concern to the medical and public health community because interdisciplinary research has consistently documented the negative health consequences for youths exposed to chronic violence.7–9Recognizing the epidemic levels of exposure to violence faced by children and adolescents across the United States, and the consequences associated with such exposure, the US associate attorney general announced the Task Force on Children Exposed to Violence in 2011 as part of the attorney general’s Defending Childhood Initiative. The task force is composed of academic experts, practitioners, youth advocates, and clinicians, and follows the 2002 workshop entitled “Children Exposed to Violence: Current Status, Gaps, and Research Priorities.” This workshop was funded by 10 federal agencies, including the National Institute of Justice, the National Institute of Mental Health, and the Centers for Disease Control and Prevention, and attended by violence researchers from diverse academic backgrounds across the United States. Relying on research in public health, psychology, criminology, and sociology, the workshop identified various consequences of exposure to community violence, including mental health effects (posttraumatic stress disorder, depression, low self-esteem, disassociation); psychobiological, physiological, and neuroendocrine effects (elevated heart rate, sleep disturbance, altered cortisol production, slower pubertal development); and psychosocial effects (substance use, conduct disorder, aggression, violence).10The task force also concluded that there are substantial variations in estimates of exposure to community violence in the literature, although most studies have examined the prevalence of violence exposure in high-risk areas.10 Not surprisingly, research has found a strong correlation between exposure to violence and neighborhood conditions such as poverty.8,11,12 Understanding the individual and contextual pathways to violence exposure in the general population, as well as in the urban community, is necessary for alleviating its damaging effects.10Subsequent interdisciplinary research has continued to identify individual, family, school, and community factors associated with exposure to violence.8,11,12 One of the strongest individual covariates of exposure to community violence is race/ethnicity. Several studies have reported higher rates of exposure to violence among racial and ethnic minorities, particularly Blacks and Hispanics, than among Whites.4,13–15 In addition, these racial/ethnic disparities persist when youths’ exposure to violence is self-reported or reported by a primary caregiver.16 Indeed, research has demonstrated that race/ethnicity is among the strongest predictors of exposure to violence, whether the informant is a parent or a child.8The etiology of these disparities remains a mystery because empirical evidence has not attempted to explain differences in exposure to violence by race or ethnicity. Individual-level studies have examined family characteristics (e.g., parents’ education and income level, family structure, parent–child conflict, parental supervision) as potential covariates of exposure to violence,3–6,15,17 but these studies have not quantified the role that family factors could play in explaining differences in exposure to violence across race/ethnicity. Studies have also found that youths reporting the highest rates of exposure to violence tend to live in the most disadvantaged neighborhoods.4,18–20 Yet with some recent and notable exceptions,11,12 multilevel analyses of exposure to violence are sparse, and community influences on exposure to violence are poorly understood.8 Recognizing these limitations, we used a multilevel framework to examine the extent to which the differential exposure to violence associated with race/ethnicity among youths can be accounted for by a constellation of individual, family, and neighborhood factors.     

Community Poverty and Trends in Racial/Ethnic Survival Disparities Among People Diagnosed With AIDS in Florida, 1993–2004

Objectives. We described the racial/ethnic disparities in survival among people diagnosed with AIDS in Florida from 1993 to 2004, as the availability of highly active antiretroviral therapy (HAART) became widespread. We determined whether these disparities decreased after controlling for measures of community-level socioeconomic status.Methods. We compared survival from all causes between non-Hispanic Blacks and non-Hispanic Whites vis-a-vis survival curves and Cox proportional hazards models controlling for demographic, clinical, and area-level poverty factors.Results. Racial/ethnic disparities in survival peaked for those diagnosed during the early implementation of HAART (1996–1998) with a Black-to-White hazard ratio (HR) of 1.72 (95% confidence interval [CI] = 1.62, 1.83) for males and 1.40 (95% CI = 1.24, 1.59) for females. These HRs declined significantly to 1.48 (95% CI = 1.35, 1.64) for males and nonsignificantly to 1.25 (95% CI = 1.05, 1.48) for females in the 2002 to 2004 diagnosis cohort. Disparities decreased significantly for males but not females when controlling for baseline demographic factors and CD4 count and percentage, and became nonsignificant in the 2002 to 2004 cohort after controlling for area poverty.Conclusions. Area poverty appears to play a role in racial/ethnic disparities even after controlling for demographic factors and CD4 count and percentage.The HIV/AIDS epidemic has disproportionately affected the non-Hispanic Black population in the United States. In 2008, an estimated 545 000 non-Hispanic Blacks were living with HIV/AIDS.1 The estimated prevalence of HIV infection for 2008 among non-Hispanic Blacks was 18.2 per 1000 population, more than 7 times higher than the estimated rate for non-Hispanic Whites (non-Hispanic Whites; 2.4 per 1000).1 Non-Hispanic Blacks as a group not only have a higher prevalence of HIV/AIDS, but once infected also have a lower survival rate. The 3-year survival rate in the United States for people diagnosed with AIDS between 2001 and 2005 was 80% among non-Hispanic Blacks compared with 84% for non-Hispanic Whites, 83% for Hispanics, and 88% for Asians,2 further contributing to the disparities in the HIV mortality rate of 16.8 per 100 000 among non-Hispanic Blacks compared with 1.6 per 100 000 among non-Hispanic Whites during 2007.3 Race/ethnicity is a fundamentally social as opposed to a biological construct,4,5 and survival disparities between non-Hispanic Blacks and non-Hispanic Whites have not generally been seen in settings with universal health care access such as in the Veterans Administration health care system,6 the military health care system,7 or a health maintenance organization.8 Therefore, potentially modifiable social explanations for the observed racial/ethnic disparities in survival should be examined.A most remarkable advance in medical treatment in the past century was the development of highly active antiretroviral therapy (HAART). It led to a significant improvement in survival from HIV/AIDS, 9–12 but racial/ethnic disparities in HIV/AIDS survival remain2, 13–16 and in New York City appeared to widen.17 Despite these well-recognized health disparities, there is a critical gap in the knowledge about why the disparity exists. Two population-based studies, both in San Francisco, California (a city that has provided free HIV care for those who cannot afford it), found that Black race was no longer associated with survival between 1996 and 2001 after controlling for neighborhood socioeconomic status (SES), and that this SES effect seemed to be related to HAART use.18,19 However, in a study using HIV surveillance data from 33 states, racial/ethnic disparities in 5-year survival after HIV diagnosis between 1996 and 2003 persisted after adjusting for county-level SES and other factors.20 The objective of this study was to describe the racial/ethnic disparities in AIDS survival in Florida among people diagnosed with AIDS between 1993 and 2004 (a period spanning the time before and during the widespread availability of HAART) and to determine if these disparities decrease after controlling for community-level SES.     

Trends in Racial and Ethnic Disparities in Childhood Asthma in Miami,Florida: 2005–2013

Nationally, racial and ethnic disparities in childhood asthma plateaued from 2005 to 2013. We assessed trends in childhood asthma in Miami, Florida using Youth Risk Behavior Surveillance System (YRBSS) data and emergency department (ED) utilization and hospitalization rates by zip code population characteristics. Asthma prevalence in Miami did not vary significantly by race/ethnicity in YRBSS respondents in 2005 (16.2–17.2%, all groups), but rose in African–Americans and Hispanics and declined in Whites by 2013 to 27.9, 20.9 and 12.6%, respectively (P?=?0.02). Median asthma ED visit rates rose from 106.8 (2006–2008) to 138.2 (2011–2013; P?=?0.004) per 10,000 children. High-poverty and majority African–American zip codes were 6.3 and 7.3 times more likely to have asthma ED visit rates?>?200 than others (P?<?0.001). In high-poverty zip codes, majority African–American population was not associated with significantly higher ED utilization. In low-poverty zip codes, the association became stronger. Greater poverty explains much, but not all of Miami African–Americans’ higher asthma risk.     

Does the Racial/Ethnic Composition of Medicare Advantage Plans Reflect Their Areas of Operation?

Objective

To assess the extent to which the racial/ethnic composition of Medicare Advantage (MA) plans reflects the composition of their areas of operation, given the potential incentives created by the Centers for Medicare & Medicaid Services'' Quality Bonus Payments for such plans to avoid enrolling racial/ethnic minority beneficiaries.

Data Sources/Study Setting

2009 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) survey and administrative data from the Medicare Enrollment Database.

Data Collection/Extraction Methods

We defined each plan''s area of operation as all counties in which it had MA enrollees, and we created a matrix of race/ethnicity by plan by county of residence to assess the racial/ethnic distribution of each plan''s enrollees in comparison with the racial/ethnic composition of MA beneficiaries in its operational area.

Principal Findings

There is little evidence that health plans are selectively underenrolling blacks, Latinos, or Asians to a substantial degree. A small but potentially important subset of plans disproportionately serves minority beneficiaries.

Conclusions

These findings provide a baseline profile that will enable crucial ongoing monitoring to assess how the implementation of Quality Bonus Payments may affect MA plan coverage of minority populations.     

Racial/Ethnic Differences in the Incidence of Kawasaki Syndrome among Children in Hawai‘i

Objective

To describe the occurrence of Kawasaki syndrome (KS) among different racial/ethnic groups in Hawai‘i.

Methods

Retrospective analysis of children <18 years of age, with a focus on children <5 years of age, living in Hawai‘i who were hospitalized with KS using the 1996–2006 Hawai‘i State Inpatient Data.

Results

Children <5 years of age accounted for 84% of the 528 patients <18 years of age with KS. The average annual incidence among this age group was 50.4 per 100,000 children <5 years of age, ranging from 45.5 to 56.5. Asian and Pacific Islander children accounted for 92% of the children <5 years of age with KS during the study period; the average annual incidence was 62.9 per 100,000. Within this group, Japanese children had the highest incidence (210.5), followed by Native Hawaiian children (86.9), other Asian children (84.9), and Chinese children (83.2). The incidence for white children (13.7) was lower than for these racial/ethnic groups. The median age of KS admission for children <5 years of age was 21 months overall, 24 months for Japanese children, 14.5 months for Native Hawaiian children and 26.5 months for white children.

Conclusions

The high average annual KS incidence for children <5 years of age in Hawai‘i compared to the rest of the United States population reflects an increased KS incidence among Asian and Pacific Islander children, especially Japanese children. The incidence for white children was slightly higher than or similar to that generally reported nationwide.     

Racial/Ethnic Specific Trends in Pediatric Firearm-Related Hospitalizations in the United States, 1998–2011

Objectives To determine the temporal patterns and the difference in trends by race/ethnicity of pediatric firearm hospitalizations (FH) among those aged 15 years or younger in the United States. Methods Data on pediatric FH was retrieved from the Nationwide Inpatient Sample between 1998 and 2011 (n = 16,998,470) using external cause of injury codes (E-codes) of the International Classification of Diseases, Ninth Revision, Clinical modification, (assault: E9650-E9654, unintentional: E9220-E9224, E9228, and E9229, suicide: E9550-E9554, E9556, and E9559, undetermined: E9850-E9854, and E9856 and legal: E970). Meta-regression was used to determine the significance of temporal trends. Survey logistic regression adjusted for survey year was used to examine association of pediatric FH with social and demographic characteristics. Results An annual reduction of 1.07 per 100,000 hospitalizations (p-trend = 0.011) was observed between 1998 and 2011. There was reduction in rate of unintentional-FH (p-trend = 0.013), suicide-FH (p-trend = 0.029), and undetermined-FH (p-trend = 0.002), but not assault-FH (p-trend = 0.18). A decline in rates of FH was observed among whites (p-trend = 0.021) and Hispanics (p-trend = 0.03) while an increase in rates of assault-FH was observed among black children. All other intents and all other racial/ethnic groups showed declining rates during this interval. Conclusions There was an overall decline in rates of pediatric FHs in this time period driven by a decline in unintentional-FHs. However there was an increase in assault FH among black children during this same time period.     

Racial/Ethnic Disparities in Knowledge about Risks and Benefits of Breast Cancer Treatment: Does It Matter Where You Go?

Objective. To evaluate the association between provider characteristics and treatment location and racial/ethnic minority patients' knowledge of breast cancer treatment risks and benefits.
Data Sources/Data Collection. Survey responses and clinical data from breast cancer patients of Detroit and Los Angeles SEER registries were merged with surgeon survey responses ( N =1,132 patients, 277 surgeons).
Study Design. Cross-sectional survey. Multivariable regression was used to identify associations between patient, surgeon, and treatment setting factors and accurate knowledge of the survival benefit and recurrence risk related to mastectomy and breast conserving surgery with radiation.
Principal Findings. Half (51 percent) of respondents had survival knowledge, while close to half (47.6 percent) were uncertain regarding recurrence knowledge. Minority patients and those with lower education were less likely to have adequate survival knowledge and more likely to be uncertain regarding recurrence risk than their counterparts ( p <.001). Neither surgeon characteristics nor treatment location attenuated racial/ethnic knowledge disparities. Patient–physician communication was significantly ( p <.001) associated with both types of knowledge, but did not influence racial/ethnic differences in knowledge.
Conclusions. Interventions to improve patient understanding of the benefits and risks of breast cancer treatments are needed across surgeons and treatment setting, particularly for racial/ethnic minority women with breast cancer.