UNEQUAL TREATMENT REVISITED: THE CURRENT STATE OF RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE

重新审视不平等待遇：医疗保健中种族和民族差异的现状

基本信息

批准号：
10710079
负责人：
ROBERT DAY
金额：
$ 12.5万
依托单位：
NATIONAL ACADEMY OF SCIENCES
依托单位国家：
美国
项目类别：
财政年份：
2022
资助国家：
美国
起止时间：
2022-09-28 至 2024-09-27
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/10710079
关键词：
Academy Acute Address Affect Affordable Care Act African American African American population Age-Years Alaska Native Ambulatory Care American Indians Area Asian Americans Asian population Automobile Driving Black race Budgets COVID-19 COVID-19 pandemic Caring Categories Characteristics Chronic Climate Clinical Communication Communication Barriers Communities Congresses Consensus Continuing Education Country Data Decision Making Diagnosis Diagnostic Diagnostic Services Discrimination Disease Economically Deprived Population Education Educational Curriculum Elderly Emergency Care Emergency Situation Engineering English Language Ethnic Origin Ethnic group Evaluation Exposure to Family Focus Groups Foundations Gender Geographic Factor Geography Graduate Education Grant Health Health Care Costs Health Insurance Health Occupations Health Policy Health Professional Health Services Accessibility Health Services Research Health system Healthcare Healthcare Systems Hispanic Hispanic Populations Hospitals Individual Inequality Infrastructure Activities Institute of Medicine (U.S.)Insurance Insurance Coverage International Internet Intervention Knowledge Laboratories Latino Latino Population Laws Lead Legal Limited English Proficiency Linguistics Literature Longevity Measures Medicaid Medical Medicare Medicine Mental Health Methods Minority Groups Modeling Monitor Native Hawaiian or Other Pacific Islander Nurses Occupational Office Management Operating System Outcome Outpatients Pacific Island Americans Patients Persons Pharmacists Physician Assistants Physician&apos s Role Plant Roots Play Policies Policy Maker Population Poverty Prejudice Preventive healthcare Primary Health Care Procedures Psychologist Public Health Publications Publishing Quality of Care Race Recommendation Recording of previous events Reduce health disparities Regulation Rehabilitation therapy Reporting Research Research Personnel Resources Review Literature Role Series Services Sick Leave Social Class Social Environment Social Work Social Workers Societal Factors Societies Stereotyping Stratification System Technology Telemedicine Testing Time Training Training and Education Transportation Treatment outcome Trust Uncertainty Underinsured Underrepresented Minority Underrepresented Populations Uninsured United States National Academy of Sciences Update Visit Work base care outcomes care seeking care systems career clinical care clinical decision-making clinical encounter clinical practice community based participatory research community engaged research cultural competence design diagnostic algorithm diagnostic tool digital disparity elimination disparity reduction dual eligible effective intervention ethnic health disparity ethnic minority ethnic minority population evidence base evidence based guidelines experience health care availability health care delivery health care disparity health care quality health care service health care service utilization health care settings health disparity health economics health equity health information technology health outcome disparity health plan health training heuristics improved individual patient insight marginalized population medical specialties minority children novel strategies operation pandemic disease patient population patient stratification population health profession allied to medicine programs public health emergency racial and ethnic racial and ethnic disparities racial disparity racial minority racial population racism social social culture social determinants social exclusion social health determinants socioeconomic disadvantage southeast Asian treatment services undergraduate education urgent care virtual healthcare

Academy Acute Address Affect Affordable Care Act African American African American population Age-Years Alaska Native Ambulatory Care American Indians Area Asian Americans Asian population Automobile Driving Black race Budgets COVID-19 COVID-19 pandemic Caring Categories Characteristics Chronic Climate Clinical Communication Communication Barriers Communities Congresses Consensus Continuing Education Country Data Decision Making Diagnosis Diagnostic Diagnostic Services Discrimination Disease Economically Deprived Population Education Educational Curriculum Elderly Emergency Care Emergency Situation Engineering English Language Ethnic Origin Ethnic group Evaluation Exposure to Family Focus Groups Foundations Gender Geographic Factor Geography Graduate Education Grant Health Health Care Costs Health Insurance Health Occupations Health Policy Health Professional Health Services Accessibility Health Services Research Health system Healthcare Healthcare Systems Hispanic Hispanic Populations Hospitals Individual Inequality Infrastructure Activities Institute of Medicine (U.S.)Insurance Insurance Coverage International Internet Intervention Knowledge Laboratories Latino Latino Population Laws Lead Legal Limited English Proficiency Linguistics Literature Longevity Measures Medicaid Medical Medicare Medicine Mental Health Methods Minority Groups Modeling Monitor Native Hawaiian or Other Pacific Islander Nurses Occupational Office Management Operating System Outcome Outpatients Pacific Island Americans Patients Persons Pharmacists Physician Assistants Physician&apos s Role Plant Roots Play Policies Policy Maker Population Poverty Prejudice Preventive healthcare Primary Health Care Procedures Psychologist Public Health Publications Publishing Quality of Care Race Recommendation Recording of previous events Reduce health disparities Regulation Rehabilitation therapy Reporting Research Research Personnel Resources Review Literature Role Series Services Sick Leave Social Class Social Environment Social Work Social Workers Societal Factors Societies Stereotyping Stratification System Technology Telemedicine Testing Time Training Training and Education Transportation Treatment outcome Trust Uncertainty Underinsured Underrepresented Minority Underrepresented Populations Uninsured United States National Academy of Sciences Update Visit Work base care outcomes care seeking care systems career clinical care clinical decision-making clinical encounter clinical practice community based participatory research community engaged research cultural competence design diagnostic algorithm diagnostic tool digital disparity elimination disparity reduction dual eligible effective intervention ethnic health disparity ethnic minority ethnic minority population evidence base evidence based guidelines experience health care availability health care delivery health care disparity health care quality health care service health care service utilization health care settings health disparity health economics health equity health information technology health outcome disparity health plan health training heuristics improved individual patient insight marginalized population medical specialties minority children novel strategies operation pandemic disease patient population patient stratification population health profession allied to medicine programs public health emergency racial and ethnic racial and ethnic disparities racial disparity racial minority racial population racism social social culture social determinants social exclusion social health determinants socioeconomic disadvantage southeast Asian treatment services undergraduate education urgent care virtual healthcare

展开

项目摘要

The Institute of Medicine’s (IOM, 2003) [Now the National Academy of Medicine as one of the National Academies of Sciences, Engineering, and Medicine, NASEM] groundbreaking report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” documented differences in the quality of healthcare services received by people from racial and ethnic minority groups, highlighting the roles that racial stratification and social inequities play in health outcomes. Published almost 20 years after the landmark Malone-Heckler report, Unequal Treatment provided compelling models and evidence demonstrating how the health care system operates on multiple levels to create, sustain, and increase racial and ethnic health disparities – emphasizing the contributions of factors beyond the control of the individual patient. Reviewing evidence from the 2003 report and data generated subsequently, NASEM will convene an ad hoc expert committee to examine the current state of racial and ethnic disparities in U.S. healthcare. Congress commissioned the IOM in 1999 to study the root causes of racial and ethnic health disparities due to the growing concern around people from racial and ethnic minority groups and people experiencing poverty becoming a “permanent health care underclass.” Due to the historical marginalization of these populations in the healthcare system, high rates of being uninsured or underinsured, along with high health care costs driving differential access, utilization and quality of care, the IOM sought to illuminate how and why key factors impacting healthcare access, utilization and quality of care contributed to health disparities. The foci were two levels of the healthcare system that were hypothesized to contribute significantly to racial and ethnic health disparities. They first examined the operation of healthcare systems and the legal and regulatory climate in which health systems function, providing more nuanced explanations that moved beyond attributing health disparities to differential healthcare access. The second focused on understanding discriminatory practices at the patient, clinician, and health system levels – measured by bias, stereotyping, and clinician/patient concordance – as causes of racial and ethnic health disparities. The report provided actionable recommendations for evidenced-based targeted interventions that could be implemented over time to improve quality of care and reduce racial and ethnic healthcare disparities. The major findings from the IOM report reinforced that healthcare system limitations had particularly negative implications for the quality of care received by Black/African American persons and certain Hispanic/Latino persons based on their birthplace or English language fluency. However, most of the available data at the time was available for Black/African American persons and there was limited information in the IOM report on other minoritized populations. Among other findings, the report concluded that: • Minoritized racial and ethnic patients often receive a lower quality of care and less intensity of indicated treatment and diagnostic services across a wide range of procedures and disease areas. • Insurance status is a key predictor of the quality of care that minoritized racial and ethnic groups receive since they are disproportionately represented in the Medicaid and dual-eligible Medicare categories and no health insurance; yet when insurance status is controlled, race and ethnicity remain significant predictors of quality of care. • Within the clinical encounter, minoritized patients may perceive both overt, as well as subtle forms of discrimination when seeking care. Bias, stereotyping, prejudice, and communication barriers on the part of clinicians and other healthcare staff may be contributory factors to racial and ethnic disparities in healthcare. • Limited assistance with professional interpretation services is available to patients with limited English proficiency, which has negative implications for the clinical encounter. • Sociocultural differences between patient and clinician influence communication and clinical decision making; thus, ineffective communication during the medical encounter may lead to patient dissatisfaction, non-adherence, poorer health outcomes, and subsequently, racial and ethnic disparities in healthcare. • A significant body of literature defines and supports the importance of cross-cultural education in the training of health professionals. Despite several approaches and various opportunities for integration, curricula in this area have been implemented to a modest degree in undergraduate, graduate, and continuing education of health professions. • Medical graduates who identify with an underrepresented minority group made up about 14% in 2019-2020, with 7% being African American, 6% Latino/a and 1% American Indian or Alaska Native and Native Hawaiian or Pacific Islander. The 22% of medical graduates who identify as Asians, include Southeast Asians who are also underrepresented. • More information is needed on the potential impacts of medical care delivered in the context of cultural and linguistic concordance between clinicians and their patients. These would include efforts to evaluate the role of physicians from underrepresented populations and that of international medical graduates and minoritized racial and ethnic populations, and specifically the extent to which this contributes to healthcare disparities. Along with identifying key areas of healthcare that create and sustain racial and ethnic disparities, the IOM report identified areas needed for further research and suggested several intervention strategies to eliminate disparities in quality of care and improve population health. These recommendations included: • Develop a better understanding of the relative contribution of patient, clinician, and institutional characteristics to healthcare disparities. • Further illuminate clinical decision-making, heuristics applied in diagnostic evaluation, and how patients' race, ethnicity, gender, English language fluency, and social class may influence these decisions. • Assess the relative contributions of clinician biases, stereotyping, prejudice, and uncertainty in producing racial and ethnic disparities in diagnosis, treatment, and outcomes of care. • Investigate the roles of non-physician healthcare professionals, including nurses, physician assistants, occupational and rehabilitation therapists, mental health professionals (including psychologists, social workers, and marital and family therapists), pharmacists, allied health professionals, as well as medical assistants, administrative, and laboratory staff in contributing to healthcare disparities. • Due to a paucity of research, assess healthcare disparities among Asian American, Native Hawaiian and Pacific Islander, American Indian and Alaska Native, and Hispanic or Latino populations and their subpopulations. • Assess the potential impacts of medical care delivered in the context of cultural and linguistic concordance between clinicians and their patients. These would include efforts to evaluate the role of physicians from underrepresented populations and that of international medical graduates and minoritized racial and ethnic populations, and specifically the extent to which this contributes to decreasing healthcare disparities. • Develop and test the utility of healthcare improvement of patient-based measures of (1) trust in clinicians and systems and (2) exposure to discriminatory practices by clinicians or systems. • Develop methods for monitoring progress toward reducing and ultimately eliminating racial and ethnic disparities in healthcare. • Understand the relationship between healthcare disparities and the health gap between racial and ethnic minority and White patients stratified by educational attainment. While the IOM report provided the foundational evidence base necessary for subsequent studies to address how healthcare related factors significantly contribute to disparities in healthcare quality for minoritized racial and ethnic persons and the approaches needed to address them, health disparities persist and, in many conditions, continue to widen. It has been 20 years since the publication of the IOM report, and factors outside of the control of the individual continue to play a significant role in disparate health outcomes. Needed is an understanding of the aspects of healthcare quality identified in the IOM report which have shown improvement, promise, or worsened. For example, a significant advancement in health care is the Patient Protection and Affordable Care Act of 2010 (ACA) which has increased insurance coverage for 20 million U.S. residents, reduced the insurance gap across all racial and ethnic groups in the U.S. and completely eliminated the disparity for Asian Americans, Native Hawaiians and Pacific Islanders, but not for other racial groups. 4 Unfortunately, there remains a considerable segment of the population that lacks access to healthcare due to lack of health insurance. The lack of insurance is most notable for Latino/Hispanic populations 18 to 64 years of age. Further, even among insured populations, numerous adverse social determinants of health—such as lack of transportation and paid sick leave—may impede access to care for marginalized groups. In addition, demographic shifts in the population and public health emergencies such as the COVID-19 pandemic have exacerbated racial and ethnic health disparities in all aspects of healthcare and health outcomes. These factors must be taken into consideration when assessing the current disparities landscape. Advancing the work of the previous IOM report will include a review of the state of racial and ethnic disparities in quality of care, access, and utilization, and expand to examine community and population level factors that operate to influence healthcare disparities. Current evidence suggests that the digital divide has hampered the potential of health information technology to expand access to healthcare for socioeconomically disadvantaged groups and racial and ethnic minority persons. 5 For example, in a study that assessed geographic and racial and ethnic disparities in access to care, Mantri & Mitchell (2021) found that with the shift to virtual care due to the COVID-19 pandemic, visits among Black/African American individuals was cut in half relative to pre-pandemic utilization. 6 Other research has also found that the COVID-19 pandemic has had an adverse impact on healthcare utilization due to limited telemedicine adoption7 and increased racial inequities in the quality and intensity of care. 8 Thus, it is important that healthcare systems emphasize access to high quality of care for all, strengthen preventive health care approaches, address social needs as part of healthcare delivery, and diversify the healthcare workforce to more closely reflect the demographic composition of the patient population.

医学研究所（IOM，2003年）[现在是美国国家医学院作为国家科学院，工程和医学学院之一，NASEM]开创性报告“不平等的待遇：在医疗保健服务质量上，与种族和种族的较小群体相遇的医疗保健质量相遇的种族和族裔差异记录了在培养型群体中的医疗保健质量的差异。在具有里程碑意义的马龙·赫克勒（Malone-Heckler）报告后近20年发布，不平等的治疗提供了令人信服的模型和证据，证明了卫生保健系统如何在多个层面上运作以创造，维持和增加种族和族裔健康分布 - 强调了超出个人患者控制的因素的贡献。回顾2003年报告和随后产生的数据的证据，NASEM将召集一个临时专家委员会，以检查美国医疗保健中种族和种族差异的现状。国会于1999年委托IOM研究赛车和种族健康差异的根本原因，因为赛车和少数民族群体的人们日益关注，以及经历贫困的人们成为“永久性医疗保健下层阶级”。由于这些人群在医疗保健系统中的历史边缘化，因此没有保险或保险不足的高率，以及促进差异访问，利用和护理质量的高医疗保健成本，IOM感知的是阐明如何以及为什么影响医疗保健访问，利用率和护理质量的关键因素以及为何有助于医疗分配。该焦点是医疗保健系统的两个级别，这些层次被认为对种族和族裔健康分配产生了重大贡献。他们首先检查了医疗保健系统的运行以及卫生系统运作的法律和法规环境的运作，提供了更细微的解释，这些解释不仅仅是将健康差异归因于差异医疗保健访问。第二个重点是理解患者，临床和卫生系统水平的歧视性实践 - 通过偏见，刻板印象以及临床/患者一致性来衡量种族和种族健康分布的原因。该报告为基于证据的目标干预措施提供了可行的建议，这些干预措施可以随着时间的推移而实施，以提高护理质量并减少种族和种族医疗保健差异。 IOM报告中的主要发现加强了医疗保健系统的限制对黑人/非裔美国人的护理质量以及基于生日或英语语言流利的某些西班牙裔/拉丁裔人的护理质量特别负面影响。但是，当时的大多数可用数据可用于黑人/非裔美国人，IOM报告中有关其他少数人口的信息有限。除其他发现外，报告得出的结论是： •在广泛的程序和疾病领域，少数少数的种族和族裔患者通常会获得较低的护理质量和较低的指定治疗和诊断服务强度。 •保险状况是少数种族和族裔获得的护理质量的关键预测指标，因为它们在医疗补助和符合双重资格的Medicare类别中的代表不成比例，没有健康保险；然而，当控制保险状态时，种族和种族仍然是护理质量的重要预测指标。 •在临床遭遇中，少数化的患者在寻求护理时可能会感知公开的歧视形式。临床医生和其他医疗保健人员的偏见，刻板印象，偏见和沟通障碍可能是医疗保健中种族和种族差异的原因。 •英语能力有限的患者可以使用专业解释服务的有限帮助，这对临床遭遇具有负面影响。 •患者和临床影响沟通和临床决策之间的社会文化差异；因此，在医疗遭遇期间的沟通无效可能会导致患者的不满，不遵守，健康结果较差，以及随后在医疗保健中的种族和种族差异。 •大量文献定义并支持跨文化教育在卫生专业人员培训中的重要性。尽管有几种方法和各种融合机会，但该领域的课程已在本科，研究生和卫生专业人员继续教育中均得以适当地实施。 •确定与代表性不足的少数群体的医学毕业生在2019 - 2020年占14％，其中7％为非裔美国人，6％的拉丁裔/a和1％的美洲印第安人或阿拉斯加人，夏威夷本地人或夏威夷人或太平洋岛民。 22％的医学毕业生认同为亚洲人，包括东南亚人，他们的人数也不足。 •需要更多信息，了解在临床医生及其患者之间的文化和语言关注背景下提供的医疗服务的潜在影响。这些将包括评估代表人群不足的医生以及国际医学毕业生以及少数种族和民族人口的努力，特别是这对医疗保健分配的贡献程度。除了确定创造和维持种族和种族差异的关键医疗保健领域外，IOM报告还确定了进一步研究所需的领域，并提出了几种干预策略，以消除护理质量的差异并改善人口健康。这些建议包括： •更好地了解患者，临床和机构特征对医疗保健分布的相对贡献。 •进一步阐明临床决策，用于诊断评估中的启发式方法，以及患者的种族，种族，性别，英语流利和社会阶层如何影响这些决策。 •评估临床偏见，刻板印象，偏见和不确定性在诊断，治疗和护理结果中产生种族和种族差异的相对贡献。 •研究非物理医疗保健专业人员，包括护士，身体助理，职业和康复治疗师，精神卫生专业人员（包括心理学家，社会工作者以及婚姻和家庭治疗师），药剂师，相关卫生专业人员以及医疗助理，行政人员，行政人员以及为医疗保健贡献贡献的工作人员。 •由于缺乏研究，亚裔美国人，夏威夷原住民和太平洋岛民，美洲印第安人和阿拉斯加人以及西班牙裔或拉丁裔人口及其亚人群之间的评估医疗保健分布。 •评估在临床医生及其患者之间文化和语言关注的背景下提供的医疗服务的潜在影响。这些将包括评估人口不足的医生以及国际医学毕业生以及少数化种族和民族人口的努力，特别是这有助于减少医疗保健分配的程度。 •开发和测试（1）对临床医生和系统信任的基于患者的措施的医疗保健效用，以及（2）临床医生或系统的歧视性实践。 •开发用于监视减少并最终消除医疗保健种族和种族差异的进展的方法。 •了解医疗保健分配与种族和少数民族之间的健康差距与通过教育成就分层的白人患者之间的关系。尽管IOM报告提供了随后的研究所必需的基本证据基础，以解决与医疗保健相关的因素如何显着促进少数赛车和民族的医疗保健质量分配以及解决方案所需的方法，但医疗分配持续存在，并且在许多情况下继续扩大。自IOM报告发布以来已有20年了，而且在个人控制之外的因素继续在不同的健康结果中发挥重要作用。需要了解IOM报告中确定的医疗保健质量方面，该报告显示出改善，承诺或恶化。例如，医疗保健方面的显着进步是2010年的《患者保护和负担得起的护理法》，它增加了2000万美国居民的保险范围，减少了美国所有种族和族裔的保险差距，并完全消除了亚裔美国人，亚裔美国人，原住民夏威夷人和太平洋岛民的差异，但没有针对其他种族群体。 4不幸的是，由于缺乏健康保险，仍有一个人口的考虑部分无法获得医疗保健。缺乏保险对于18至64岁的拉丁裔/西班牙裔人口最引人注目。此外，即使在被保险人群中，许多不利的健康决定者（例如缺乏运输和带薪病假）也可能阻碍边缘化群体获得护理的机会。此外，在医疗保健和健康成果的各个方面，人口和公共卫生紧急情况的人口转变（例如COVID-19大流行）加剧了赛车和种族健康差异。在评估当前分布格局时，必须考虑这些因素。推进上一份IOM报告的工作将包括对医疗质量，获取和利用质量的种族和种族差异的审查，并扩展到对影响医疗保健分布的社区和人群层面的研究。当前的证据表明，数字鸿沟阻碍了健康信息技术的潜力扩大社会经济弱势群体以及种族和种族少数民族的医疗保健的机会。 5例如，在一项评估地理，种族和族裔分布的研究中，Mantri＆Mitchell（2021）发现，由于COVID-19的大流行，黑人/非裔美国人的访问被削减了一半的相对于PARDEMIC PERIPATION的访问。 6其他研究还发现，由于远程医疗的采用有限和护理质量和强度的种族不平等，COVID-19大流行对医疗保健利用产生了不利影响。 8这是，重要的是，重要的是，医疗保健系统强调获得所有人的高质量护理，增强预防性医疗保健方法，解决社会需求，作为医疗保健提供的一部分，并使医疗保健劳动力多样化，以更紧密地反映患者人群的人口统计学组成。