Anyone who practices medicine realizes there are disparities in the provision of health services," says David Carlisle. "You know it's related to insurance status and it's related to income — but it's also related to ethnicity." So in the late '80s, when researchers studying the state of Massachusetts first began reporting evidence that an individual's ethnic origin can affect the medical treatment he or she receives, Carlisle, who was on a fellowship at UCLA, wasn't exactly surprised. He was, however, intrigued that the studies had been done in parts of the country that have small, relatively homogenous populations. What if the treatments could be studied in a much larger population like Los Angeles, where a variety of ethnic groups are represented in large numbers?
"I thought we could not only do a better analysis, but also expand the variety by including ethnic groups not included in the other studies," says Carlisle, who's an assistant professor of medicine at UCLA. Understanding ethnic factors involved in medical treatment could provide a means to improve medical care that would be as meaningful as developing a new treatment or understanding the basic biology of a disease.
Making use of a unique database collected by the Office of Statewide Health Planning and Development, which detailed patient care in California during 1986-'88, Carlisle focused on the use of three hospital-based cardiac procedures performed on residents of Los Angeles County — an ethnic melange with about 3 percent of the nation's population. Carlisle and his colleagues were also the first to look at how race affected the cardiac care not only of African Americans, but also Latinos and Asians. What they found was that African Americans, Latinos and Asians in Los Angeles are all less likely to undergo lifesaving procedures such as coronary angioplasty than white patients. But there was a new twist.
In the case of Asians and Latinos, Carlisle and his colleagues found that many of the inequities in the cardiac care was because these groups tend to receive medical care at hospitals that either perform the three cardiac procedures in low volumes or do not perform them at all.
That was not the case, however, for African Americans. "Even in the highest volume hospitals, where patients should be getting these procedures if they need them, there is a disparity for African Americans that you do not find for Latinos or Asians," says Carlisle. Even when all possible factors were considered for African Americans — socioeconomic status, severity of illness and hospital volume — they were only 60 percent as likely as whites to undergo heart bypass and 80 percent as likely to undergo angioplasty.
"Why should there be a disparity of high-volume hospitals?" says Carlisle. "It may be overt or covert racism or discrimination. There may be something going on in the patient-physician relationship where either the procedure is not offered or is not accepted because of a lack of trust or communication. There is much more to medicine than simply the technical application of our scientific armaments. As it turns out, it's the allocation of the technology that drives the health care people receive."
Presently, Carlisle is examining how race and socioeconomic status affect the medical care received under differing medical plans like health maintenance organizations and traditional fee-for-service plans — findings that could be important as government officials consider major changes to Medicare and Medicaid. But like anything in medicine, discovering cures is not easy.
"It's easy to spin your computer tapes and raise lots of questions from data like this," Carlisle says. "But it's difficult to answer the questions because you have to go out into the field, you have to interview patients, you have to get medical records and you have to do it at a broad spectrum of hospitals. That's politically difficult — and it's very expensive."
— Warren Robak |