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Differences, Disparities, and Biases: Clarifying Racial Variations in Health Care Use

Saif S. Rathore, MPH; and Harlan M. Krumholz, MD, SM
[+] Article, Author, and Disclosure Information

From Yale University School of Medicine and the Yale–New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut.

Grant Support: By National Institutes of Health Institute of General Medical Sciences Medical Scientist Training grant GM07205 (Mr. Rathore).

Potential Financial Conflicts of Interest: None disclosed.

Corresponding Author: Harlan M. Krumholz, MD, SM, Department of Internal Medicine, Room I-456 SHM, Yale University School of Medicine, 333 Cedar Street, PO Box 208088, New Haven, CT 06520-8088.

Current Author Addresses: Mr. Rathore and Dr. Krumholz: Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, Room I-456 SHM, 333 Cedar Street, PO Box 208088, New Haven, CT 06520-8088.

Ann Intern Med. 2004;141(8):635-638. doi:10.7326/0003-4819-141-8-200410190-00011
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Studies documenting racial differences in health care use are common in the medical literature. However, observational studies of racial differences in health care use lack a framework for interpreting reports of variations in health care use, leading to various terms, ranging from “variations” to “bias,” that suggest different causes, consequences, and, ultimately, remedies for such variations in treatment. We propose criteria to assess racial differences in health care use by using a clinical equity (equal treatment based on equal clinical need) framework. This framework differentiates between initial reports of racial differences and subsequent classifications of their findings as racial disparities or racial bias in health care use. Racial variations in health care use may be considered disparities after demonstrating that racial differences are not attributable to treatment eligibility, clinical contraindications, patient preferences, or confounding by other clinical factors and are associated with adverse consequences. Racial bias with adverse consequences in health care may be inferred if a racial variation in treatment that has been characterized as a disparity persists after accounting for health care system factors (for example, type of hospital at which the patient was treated). We apply this framework to published reports of racial differences in treatment to determine which studies provide evidence of differences, disparities, and bias. We discuss the use of such a framework in directing policy interventions for alleviating inappropriate racial variations in health care use.





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Conceptual Framework for Patients' Preferences and Disparity in Health Care Use
Posted on December 15, 2004
Adrian D Kenny
Harvard Medical School and Brigham and Women's Hospital
Conflict of Interest: None Declared

Letter to the Editor:

Rathore and Krumholz (October 19 issue)(1) summarize essential concepts regarding research on ethnic, racial and other disparities in health care use. Specifically they define "difference," "disparity" and "bias," as components of a three-tiered framework for disparities research. Based on these concepts the authors propose five formal criteria for determining whether a difference in treatment or health care use should be identified as a disparity. The authors suggest that patients' preferences should be thoroughly examined and accounted for in the decision to categorize a variation in health care use as a "˜disparity'. While we agree with the authors that patients' preferences may contribute to variation in health care use, we are concerned that this approach may implicitly characterize preferences as fixed personal attributes that should be accepted at face value.

On the contrary, as we have noted elsewhere, we believe that patient preferences are dynamic and reflect patient-provider communication, health literacy and knowledge, trust and compatibility with physicians, subtle or overt discrimination, level of health insurance, resources for out of pocket costs, geographic proximity to care and adequate transportation, as well as cultural tradition that may favor less invasive or alternative treatments (2). When, for example, an African American patient says he or she does not wish to have a particular surgery, we must wonder whether this preference reflects a well informed balancing of risks and benefits or, alternatively, overestimation of risks, concern about costs, and deeply held fears of receiving care in hospitals that for generations denied his or her forebearers entry. Patient preferences may obscure disparities unless we consider the range of social, economic and cultural factors that give rise to preferences.

On a practical note, we suggest a few simple questions that researchers and providers can use to reflect and elicit more authentic and well informed preferences: 1. Is the patient well informed about the treatment options? 2. Have the available options for treatment been communicated in a manner that the patient understands? 3. Are the patient's estimates of risk and benefit realistic? 4. How did the patient develop his or her expectations of outcome? Does the patient know anyone who has had the treatment? What was the outcome? 5. What other barriers to optimal treatment exist and which are potentially influenced by the provider? Naturally, we must respect patients' preferences for treatment options. However, cognizant of the social and historical context in which preferences are formed, we should make the effort to elicit preferences that are authentic and ensure we have time to address patients' preferences during each patient-provider encounter.


(1) Rathore SS, Krumholz HM. Clarifying racial variation in health care use. Annals of Internal Medicine. 2004;141:635-638 [PMID: 15492343]

(2) Katz JN. Patient preference and health disparities. JAMA. 2001;286:1506-1508 [PMID: 11572745]


Adrian Kenny, Doris Duke Charitable Foundation Clinical Research Fellow, Harvard Medical School

Elena Losina, PhD, Assistant Professor of Biostatistics, Boston University School of Public Health

Jeffrey N. Katz, MD, MSc, Associate Professor of Medicine, Harvard Medical School, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital

Address correspondence to:

Adrian Kenny

260 Longwood Ave., MEC 233, PME-Cannon Society, Boston, MA 02115.


Conflict of Interest:

None declared

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