Disparities in the criminal justice system have replaced health disparities in the headlines recently. Is this because health disparities have improved? Some recent articles confirm my suspicion that the answer is mostly no.
Two New England Journal of Medicine articles and one editorial examine this question. In one article, researchers examined racial differences in performance on 17 process-of-care quality measures – for example, did patients with heart attacks or pneumonia receive appropriate medications. In 2005, quality of care was substantially worse for black and Latino patients compared with non-Latino whites. In 2010, the performance gap had improved substantially. That seems like good news. However, in another article in the same issue, racial differences in actual health outcomes (such as control of high blood pressure or diabetes) among Medicare recipients persisted from 2006 to 2011 nationally, though there were improvements in some regions.
How to reconcile these two reports? Of course the populations and methods are somewhat different. But a larger point is that reducing disparities in health care does not necessarily translate to reducing disparities in health. Health care is one of many determinants of a person’s health, and only accounts for about 10% of health status. The remaining 90% is due to genetics, behavior, and environment. Improving health takes a lot more than improving health care.
Even in regard to disparities in care, the evidence is not necessarily encouraging. The findings of an article in Pediatrics were fairly provocative. Using national data, authors found that adherence to prescribing guidelines for otitis media was actually better for black children than non-black children, which seems like good news. However, the difference was due to less prescribing of broader-spectrum, more expensive (and not recommended) antibiotics for black children. These national data confirm early, localized findings from other studies. While it would be nice to attribute this to more diligence by providers when treating blacks, a more realistic explanation is less parental pressure for expensive antibiotics – or more likely less anticipation by the provider of such pressure – for blacks compared with whites. The authors of an accompanying editorial describe this as an example of “structural racism.”
Eliminating health disparities is going to take more than changing prescribing. It will require addressing those behavioral and environmental factors that are the primary determinants of our health. It means Ferguson, MO needs to have more in common with the nearby but much more affluent suburb of Ladue.
I’m curious, of the other ninety percent of determinants of health how much is genetic, behavior, and environment. And are they not colinear in some regards. It also struck me about the parental pressure issue for white families, other examples would be in CT rates in children for appendicitis and head injury. (I recently published a study in journal of pediatrics that found that white children were more likely to get ct for appendicitis in kids with moderate risk)
Yes, this data on prescribing is consistent with data on imaging. As far as the other determinants, current thinking is that it’s roughly 20% environment, 30% genetics, and 40% behavior, though as you mention, these are not truly independent. For example, exercise is a behavior, but it’s highly influenced by the environment (e.g., safge places to play).