Equity and equal access to care are increasingly important priorities in the health care environment.
Multiple barriers limit access to medical care, barriers that disproportionately affect different portions of society. A symposium on Wednesday will focus on the influence of race and ethnicity on outcomes in three different rheumatic diseases — lupus, rheumatoid arthritis, and total joint arthroplasty.
Despite significant advances in treatment and “tight control” strategies in rheumatoid arthritis, racial/ethnic disparities in processes of care and outcomes persist, according to Jennifer Barton, MD, Assistant Professor of Medicine at Oregon Health & Science University in Portland, and Attending Rheumatologist at the VA Hospital in Portland.
“African Americans and Hispanics with RA have been shown to have higher disease activity and poorer function when compared to whites, even when adjusting for medications,” she said. “Research has also shown significant variation in receipt of disease-modifying anti-rheumatic drugs (DMARDs) by race and ethnicity as well as other factors, with African Americans being less likely to receive DMARDs compared to whites.”
Mechanisms by which disparities can occur include variation within the health care system, the patient-clinician interaction, and on an individual level. Approaches to reducing disparities in rheumatoid arthritis, Dr. Barton said, may include a focus on supporting increased diversity of the rheumatology workforce, improving patient-clinician communication, and working to engage all patients in decision-making.
“The persistence of racial and ethnic disparities in rheumatoid arthritis outcomes is not well understood,” Dr. Barton said. “Rheumatology clinicians, researchers, policy makers, and patients need to actively work to better understand mechanisms by which these disparities occur and develop and test interventions to reduce and eliminate disparities moving forward.”
Racial disparities in joint replacement utilization and outcomes among African Americans will be the topic of a presentation by Susan M. Goodman, MD, Associate Professor of Medicine, Weill Cornell Medical College in New York City.
“Arthroplasty for end-stage osteoarthritis is arguably one of the most successful operations performed, yet there is marked racial variation in the rate of arthroplasty utilization that has not changed over decades, despite an equivalent prevalence of osteoarthritis,” Dr. Goodman said.
The lowest rates of arthroplasty utilization are seen for black men and have persisted over decades, she said, as have significantly lower rates for multiple other high-value procedures, including coronary artery angioplasty, carotid endarterectomy, spine surgery, and aneurysm repair.
“The reasons are not clear,” she said. “When providers are evaluated by video, few racial differences have been noted in patient-provider communications. Nonetheless, 40 percent of blacks in one study perceived discrimination in the health care setting, and more than half of blacks felt they received poorer services, less courtesy, and less respect in health care settings compared to 10-15 percent of whites.”
Disparities in arthroplasty utilization may be associated with outcomes, Dr. Goodman said. Previous studies have reported more post-operative pain and worse function after arthroplasty for blacks compared to whites; however, the role socio-economic status plays may be more significant than race.
“When we looked at the data in our institutional arthroplasty registry, we found the difference in outcome between blacks and whites after total knee arthroplasty (TKA) was small,” she said. “We next used geocoding to link the individual-level data to U.S. Census tract data, enabling us to analyze outcomes at different levels of community poverty. We found that community poverty level had a significant interaction with race.”
In communities with little poverty, they found there was little difference in TKA pain or function at two years between blacks and whites.
“However, as we increased the poverty level in our model, the outcomes for blacks worsened significantly, while the outcomes for the white patients remained stable,” Dr. Goodman said. “This confirmed the important contribution of socioeconomic factors to health outcomes and demonstrated a significantly greater impact of increasing poverty on blacks than whites.”
The symposium will also include a presentation on the impact of race and ethnicity on outcomes in systemic lupus erythematosus (SLE) by Ernest Vina, MD, MS, Assistant Professor at the University of Arizona College of Medicine.
Dr. Vina said that SLE was more prevalent in racial and ethnic minorities.
“SLE all-cause mortality rates are higher in certain groups, such as African Americans and Native Americans,” Dr. Vina said. “There is strong evidence that social determinants of health, such as poverty and limited access to care, greatly contribute to health disparities in lupus. Other variables, such as perceived racism in health care and lower trust in physicians, may also affect health outcomes of lupus patients.”