Kevin A Schulman MD

1
Are all patients created equal?

• Kevin A Schulman MD
• Director, Center for Clinical and Genetic
  Economics
• Duke Clinical Research Institute
• Duke University Medical Center
• Durham, NC

2
Treatment and race

• Treatment a heart patient receives may depend
  partly on the race of the patient.
• Insurance may be related to these differences in
  access in procedures.
• However, recent studies have suggested that even
  for patients in the same healthcare system,
  blacks are still less likely to receive cardiac
  procedures than whites for a given diagnosis.

3
Survival and race

• One study demonstrated that differences in
  procedure rates directly contributed to
  differences in survival for patients with
  cardiovascular disease.
• Peterson ED, et al. N Engl J Med
  1997336(7)480-486
• Among patients with cancer, a recent study showed
  that differences in access to lung cancer surgery
  for patients with resectable non-small-cell lung
  cancer (stage I or II) contributed to better
  survival by white than black patients.
• Bach PB, et al. N Engl J Med 1999341(16)1198-120
  5

4
Lung cancer treatment
Study design

• Participants were 10 984 black and white
  patients, 65 years of age or older, who were
  given a diagnosis of resectable non-small-cell
  lung cancer (stage I or II) between 1985 and 1993
  and who resided in 1 of the 10 study areas of the
  Surveillance, Epidemiology, and End Results
  (SEER) program.
• Data on the diagnosis, stage of disease,
  treatment, and demographic characteristics of the
  patients were obtained from the SEER database.
• Information on coexisting illnesses, type of
  Medicare coverage, and survival was obtained from
  linked Medicare inpatient-discharge records.

Bach PB, et al. N Engl J Med 1999341(16)1198-120
5
5
Lung cancer treatment
Results and conclusions
Black patients Whitepatients p value
Rate of surgery 64.0 76.7 plt0.001
5-year survival rate 26.4 34.1 plt0.001

• Among those undergoing surgery, survival was
  similar for the 2 racial groups the same was
  true among those who did not undergo surgery.
• The lower survival rate among black patients with
  early-stage non-small-cell lung cancer than among
  white patients may by largely explained by the
  lower rate of surgical treatment among blacks.
• Efforts to increase the rate of surgical
  treatment for black patients may improve survival
  in this group.

Bach PB, et al. N Engl J Med 1999341(16)1198-120
5
6
CVD procedure rates
Study design

• Duke University study of 12 402 patients with
  coronary disease (10.3 were black).
• Outcome measures
• whether racial differences in the use of coronary
  angioplasty and bypass surgery were evident among
  patients with documented coronary disease on
  cardiac catheterization
• whether differences in clinical history, severity
  of disease, anginal symptoms, coexisting illness,
  or access to cardiovascular care in
  subspecialties accounted for the treatment
  differences
• the use of revascularization procedures in blacks
  and whites as a function of the underlying
  severity of angina and the estimated survival
  benefit due to the procedures
• comparison of unadjusted and adjusted long-term
  survival rates among blacks and whites

Peterson ED, et al. N Engl J Med
1997336(7)480-486
7
CVD procedure rates
Study results

• After adjustment for the severity of disease and
  other characteristics, black patients were 13
  less likely than white patients to undergo
  angioplasty and 32 less likely to undergo bypass
  surgery.
• The adjusted blackwhite odds ratios (OR) for
  receiving these procedures were 0.87 (95 CI,
  0.73 to 1.03) for angioplasty and 0.68 (95 CI,
  0.56 to 0.82) for bypass surgery.
• The racial differences in rates of bypass surgery
  persisted among those with severe anginal
  symptoms (31 of black patients underwent surgery
  vs 45 of white patients plt0.001) and among
  those predicted to have the greatest survival
  benefit from revascularization (42 vs 61,
  plt0.001).
• Unadjusted and adjusted rates of survival for 5
  years were significantly lower in black than in
  white patients.

Peterson ED, et al. N Engl J Med
1997336(7)480-486
8
CVD procedure rates
Study conclusions

• Black patients with coronary disease were
  significantly less likely than white patients to
  undergo coronary revascularization, particularly
  bypass surgery a difference that could not be
  explained by the clinical features of their
  disease.
• The differences in treatment were most pronounced
  among those predicted to benefit the most from
  revascularization.
• These differences also correlated with a lower
  survival rate in black patients therefore
  coronary revascularization appears to be
  underused in this population.

Peterson ED, et al. N Engl J Med
1997336(7)480-486
9
Kidney transplantation
Study design

• 1392 patients 384 black women, 354 white women,
  337 black men, and 317 white men
• Patients with end-stage renal disease (age range
  18 to 54 years) were interviewed approximately
  10 months after they had begun maintenance
  treatment with dialysis.
• Participants were selected from a stratified
  random sample of patients undergoing dialysis in
  4 regions of the United States (Alabama, southern
  California, Michigan, and the mid-Atlantic
  region) in 1996 and 1997.
• Patients were followed until March 1999.

Ayanian JZ, et al. N Engl J Med
1999341(22)1661-1669
10
Kidney transplantation
Study results

• Patients wanting a transplant 76.3 of black
  women vs 79.3 of white women 80.7 of black men
  vs 85.5 of white men
• Patients very certain about this preference
  58.3 for black women vs 65.3 for white women
  64.1 for black men vs 75.7 for white men
  (plt0.01 for each comparison with both sexes
  combined)
• Rates of referral for transplantation evaluation
  50.4 for black women vs 70.5 for white women
  53.9 for black men vs 76.2 for white men
  (plt0.001 for each comparison).
• Placement on a waiting list or transplantation
  within 18 months of beginning dialysis 31.3 for
  black women vs 56.5 for white women 35.3 for
  black men vs 60.6 for white men (plt0.001).
• These differences remained significant after
  adjustment for patient preference and
  expectations about transplantation,
  sociodemographic characteristics, the type of
  dialysis facility, perceptions of care, health
  status, cause of renal failure, and the presence
  or absence of coexisting illnesses.

Ayanian JZ, et al. N Engl J Med
1999341(22)1661-1669
11
Kidney transplantation
Study conclusions

• In the United States, the preferences and
  expectations with respect to kidney
  transplantation among patients with end-stage
  renal disease differ according to race.
• These differences, however, explain only a small
  fraction of the substantial racial differences in
  access to transplantation.
• Physicians should ensure that black patients who
  want kidney transplantation are fully informed
  about it and are referred for evaluation.

Ayanian JZ, et al. N Engl J Med
1999341(22)1661-1669
12
Cardiac catheterization
Study design

• Interviews were recorded in which actors
  portrayed patients with scripted characteristics
  and symptoms.
• 720 physicians viewed a recorded interview and
  were given other data about the hypothetical
  patient the physicians then made recommendations
  about that patient's care.
• A computerized survey assessed the physicians'
  recommendations for managing chest pain.
• Multivariate logistic-regression analysis was
  used to assess the effects of the race and sex on
  treatment recommendations, while controlling for
  physician assessment of the probability of
  coronary artery disease and for the age of the
  patient, level of coronary risk, type of chest
  pain, and results of an exercise stress test.

Schulman KA, et al. N Engl J Med
1999340(8)618-626
13
Cardiac catheterization
Study results

• The mean (SD) estimates of the probability of
  coronary artery disease were lower for women
  (64.119.3 vs 69.218.2 for men plt0.001),
  younger patients (63.819.5 for patients who
  were 55 years old vs 69.517.9 for patients who
  were 70 years old plt0.001), and patients with
  nonanginal pain (58.319.0 vs 64.418.3 for
  patients with possible angina and 77.114.0 for
  those with definite angina plt0.001).
• Logistic-regression analysis indicated that women
  (OR0.60 95 CI0.4 to 0.9 p0.02) and black
  patients (OR0.60 95 CI0.4 to 0.9 p0.02)
  were less likely to be referred for cardiac
  catheterization than men and white patients.
• Analysis of race-sex interactions showed that
  black women were significantly less likely to be
  referred for catheterization than white men
  (OR0.4 95 CI0.2 to 0.7 p0.004).

Schulman KA, et al. N Engl J Med
1999340(8)618-626
14
Cardiac catheterization
Study conclusions

• The race and sex of a patient may independently
  influence the way physicians manage chest pain.
• Decision-making by physicians may be a factor in
  explaining differences in the treatment of
  cardiovascular disease with respect to race and
  sex.

Schulman KA, et al. N Engl J Med
1999340(8)618-626
15
Medical students' ratings
Study design

• The influence of race and sex on medical
  students' perceptions of patients' symptoms were
  evaluated to determine whether there are
  differences in these perceptions early in medical
  training.
• 164 medical students were randomly assigned to
  view a video of a black female or white male
  actor portraying patients with identical symptoms
  of angina.
• Students' perceptions of the actors' health state
  (based on their assessment of quality of life)
  were evaluated using a visual analog scale and a
  standard rating technique the type of chest-pain
  diagnosis was also evaluated.

Rathore SS, et al. Am J Med 2000108(7)561-566
16
Medical students' ratings
Study results

• Students assigned a lower value (indicating a
  less desirable health state) to the black woman
  than to the white man (mean visual scale
  scoreSD 7213 vs 6712, plt0.02 standard
  gamble 8710 vs 8015, plt0.001).
• Nonminority students reported a higher mean value
  for the white male patient (standard gamble 898
  vs 8114 for the black female patient), whereas
  minority students' assessments did not differ by
  patient.
• Male students assigned a slightly lower value to
  the black female patient (standard gamble 7616
  vs 8710 for the white male patient).
• Students were less likely to characterize the
  black female patient's symptoms as angina (46 vs
  74 for the white male patient, p0.001).

Rathore SS, et al. Am J Med 2000108(7)561-566
17
Medical students' ratings
Study conclusions

• The way that medical students perceive patient
  symptoms appears to be affected by nonmedical
  factors.
• Physicians are actually no different than anyone
  else, in that they have attitudes about people of
  other races, other socioeconomic status that
  effect treatment recommendations.
• Although physicians are not responsible for all
  the differences in treatment recommendations that
  we find in the epidemiologic literature, there is
  no reason for there to be any contribution by
  physicians to these processes.

Rathore SS, et al. Am J Med 2000108(7)561-566
18
Improving curricula

• As physicians, we have to admit that we carry
  these biases and learn how to deal with them.
• Legislation currently before Congress would
  provide an opportunity to test how to implement
  the curriculum, how to evaluate how effective we
  are in doing that, and evaluate whether or not
  students are responding to the educational
  messages.
• Section 402 of the Health Care Fairness Act of
  1999Not later than 1 year after the date of
  enactment of this Act, the Secretary of Health
  and Human Services shall convene a national
  conference on continuing medical education as a
  method for reducing disparity in health care and
  health outcomes, including continuing medical
  education on cultural competency. The conference
  shall include sessions to address measurements of
  outcomes to assess the effectiveness of curricula
  in reducing disparity.

http//thomas.loc.gov/cgi-bin/query/D?c1064./tem
p/c106JLQh2Le40492
19
AMA policy
Cultural sensitivity training

• The AMA has some policy statements calling for
  training on the part of practicing physicians.
• AMA Policy H-350.984 (AMA Policy Compendium)
  expresses zero tolerance of the clearly
  identified racial and ethnic disparities in
  health care.
• Policy H-65.984 and Council on Ethical and
  Judicial Affairs Opinion E-9.035 (AMA Policy
  Compendium) stress that academic and other
  medical institutions should offer educational
  programs about gender and cultural issues to
  staff, physicians in training, and students.
  These policies reflect the Associations
  understanding that knowledge and tolerance of
  cultural diversity is integral to effective
  health care delivery and that it must encourage
  physicians and health care organizations to
  respond to the social, cultural, economic, and
  political diversity of their communities,
  including serious consideration of cultural
  solutions to illness.

www.ama-assn.org/mem-data/special/mdschool/cultcom
p.htm
20
A changing community

• The community physicians are practicing in today
  is less homogeneous than it was when many
  physicians were trained, and it is going to
  become increasingly heterogeneous in the future.
• Until an effective curriculum is established,
  most physicians are reluctant to have such
  training mandated.
• Ideally, all physicians should look at their own
  practices and think about ways to understand
  their failings as providers and explore ways to
  overcome such failings.