Racial and ethnic
disparities and inequality are central issues in the health and political debate in the United States. Notwithstanding the massive efforts put into closing the healthcare gaps for minorities, evidence suggests that disparities stubbornly persist.
One area that remains largely unknown is the trend of racial disparity in the quality of primary care. A study by Dana Mukamel and colleagues in the November 2015 issue of Medical Care explored this important topic by examining the magnitude and longitudinal trends in racial disparities in hospitalization rates for ambulatory care sensitive conditions (ACS).
Hospitalization rates for ACS conditions have long been used as a quality indicator for primary care. Using 2003-2009 Agency for Healthcare Research and Quality (AHRQ) hospital discharge data from 6 geographically and demographically diverse states, Mukamel et al found that African Americans continue to experience poorer quality primary care, especially for chronic conditions.
According to the study, the crude overall and chronic ACS hospitalization rates were higher for African Americans throughout the study period, and the disparities increased over time. While hospitalization rates declined steadily for whites, rates for African Americans continued to climb up (indicating worsening quality over time), resulting in wider gaps. The hospitalization rates for acute ACS conditions demonstrated a different picture but still implied disparities in quality improvement: hospitalization rates were higher for whites but exhibited a decreasing trend; on the contrary, the same quality indicator for African Americans showed virtually no improvement over time.
The patterns persisted when the authors controlled for population demographics, economic, health status, and insurance enrollment characteristics. These factors vary over time and cannot be accounted for by the county fixed-effects; hence, they may result in omitted variable bias if not included in the model. The multivariate analyses further revealed that majority of the disparities were driven by gaps in admissions for ACS chronic conditions, rather than acute conditions. More interestingly, the disparities were larger in counties where African Americans are more concentrated.
This study provides strong evidence for persistent racial disparities in primary care quality, and suggests areas that warrant particular attentions for policymakers and future research. According to the study, the widest gaps exists in the care for chronic conditions and in counties with the largest number of African American population. Although what might drive these heterogeneous effects remains unclear, the evidence suggests that policy efforts should focus on the improvement of chronic care, and communities where minorities are most concentrated.
