Only one-third of cardiologists believe racial and ethnic disparities in care occur often in the United States

Only one-third of cardiologists surveyed believe racial and ethnic disparities in care occur often in the United States despite extensive documentation of the problem, according to a survey published in a special disparities issue of Circulation: Journal of the American Heart Association.

In the 2004 Rand Corporation survey, 34 percent of cardiologists agreed that differences in care based solely on race or ethnicity occur in overall health care. Thirty-three percent also agreed such disparities occur specifically in cardiovascular care. However, only 12 percent agreed that disparities existed in their own hospitals, and only 5 percent said their own patients were treated differently depending on their race or ethnicity.

"The most striking finding was the really big disconnect between what physicians report about the system in general and what they report in their own hospital and in the patients they treat," said lead investigator Nicole Lurie, M.D., M.S.P.H., the Paul O'Neill Alcoa professor of policy analysis at the RAND Corporation in Arlington, Va.

"For disparities to be occurring at the magnitude they are, they can't all be somebody else's patients. If we really want to make a difference, helping people look at their own practices and hospitals is paramount," she said.

Researchers randomly e-mailed invitations to participate in the Web-based survey to 1,371 members of the American College of Cardiology, American Heart Association, Association of Black Cardiologists and Society of Thoracic Surgeons. A total of 344 practicing cardiologists completed the survey. Of the 323 respondents who provided demographic information, 83 percent were male, 72 percent were white, 72 percent graduated medical school before 1985 and 58 percent practiced in a setting in which less than a quarter of the patients were racial or ethnic minorities.

Results indicated that physicians who were female, or black, or who treated a large number of minority patients in their practices were more likely than other cardiologists to report that disparities occur often. Females were more than twice as likely to agree that there are disparities compared to males, and black physicians were five times more likely to agree, compared to white physicians.

Most physicians agreed with the statement that people receive different care based on whether they are insured (69 percent) or on the type of insurance they have (58 percent).

"Although insurance is important, disparities in access to care and quality of care exist independent of insurance," Lurie said.

Interestingly, Lurie said, more than 60 percent of the providers surveyed rated the evidence documenting racial and ethnic disparities in cardiovascular care as "strong" or "very strong." But researchers couldn't explain why physicians' ratings of the strength of the evidence did not match provider's beliefs about the existence of disparities.

The top factors cardiologists cited to explain disparities involved the health care system (insurance and lack of time) and the patients themselves (failure to adhere to treatment, health behaviors, attitudes towards doctors, and understanding of treatment). Few respondents cited physician factors: about 40 percent of the physicians thought that miscommunication contributed greatly to disparity, and only 25 percent considered physician attitudes to be important.

To overcome disparities, 59 percent felt that increasing patients' self-management skills would be effective and 53 percent felt that expanding health insurance would help. In contrast, fewer than 30 percent of cardiologists felt increasing physician awareness or improving cultural competence of either the health provider or the institution would be useful in addressing disparities.

"Many of the physicians see a patient's attitude and ability to understand and follow treatment advice as important factors in explaining disparities," Lurie said. "There are certainly data to support the fact that patients who are members of minority groups report more problems understanding the advice they are given. When you ask physicians' about miscommunication with patients, or their own attitudes, they don't rate those as such big factors in contributing to disparities."

While researchers did not have baseline information, they were disappointed by the general lack of awareness of disparities. Several organizations have been spotlighting this issue. A report from the Henry J. Kaiser Family Foundation and the American College of Cardiology assessing racial and ethnic disparities was released in 2002. Results were published on the web and directly mailed to about 5,000 cardiologists. The American Heart Association also held a Minority Health Summit in 2003, the results of which are reported in this issue of Circulation: Journal of the American Heart Association.

Encouraging physicians to examine their own quality of care stratified by race/ethnicity data may help increase awareness, Lurie said.

"It's great to have solid national and statewide data, but one of the important ways to increase awareness of disparities is to help health plans, doctors and nurses look in their own back yards and understand what goes on in their own hospitals and practices," she said.

"Even if awareness is slow to increase, some data suggest that improving quality of care through the use of practice guidelines can play an important role in addressing racial and ethnic disparities," the researchers note.

The American Heart Association already has such a program in place: Get With the GuidelinesSM (GWTG), a quality improvement program focused on patients with ischemic heart disease, stroke or congestive heart failure. It has been shown that GTWG can improve evidenced-based care in hospitals and appears to reduce disparities in care as well.

The American College of Cardiology also has an in-hospital quality initiative and the Robert Wood Johnson Foundation recently launched a quality improvement initiative focused directly on reducing disparities.

"In the long run, no single intervention is likely to reduce or eliminate disparities," researchers conclude. "Nevertheless, the combination of increasing awareness, improving quality and increasing patients demand for and participation in high-quality care will likely contribute to addressing this important social issue."

Co-authors are Allen Fremont, M.D., Ph.D.; Arvind K. Jain, M.S.; Stephanie L. Taylor, Ph.D.; Rebecca McLaughlin, B.A.; Eric Peterson, M.D., Ph.D.; B. Waine Kong, Ph.D., J.D.; and T. Bruce Ferguson, Jr., M.D.