Minority and Rural Health

Wide variations found in hospitalization patterns for blacks and whites

Whites are hospitalized more often than blacks, and the types of conditions for which black and white patients are hospitalized vary considerably, according to a new report by researchers in the Center for Delivery Systems Research, Agency for Health Care Policy and Research. The report, authored by Anne Elixhauser, Ph.D., D. Robert Harris, Ph.D., and Rosanna M. Coffey, Ph.D., compares rates of hospital discharges by principal diagnosis for black and white patients based on a national sample of hospitals (The Hospital Cost and Utilization Project-2, HCUP-2). This report is one of a series of four publications examining variations over time in hospital discharges from 1980-1987.

Analysis of HCUP-2 data showed that white patients were hospitalized more often for 30 conditions, whereas blacks were hospitalized more often for 22 conditions. Black patients were hospitalized more frequently for diabetes mellitus, hypertension, and renal disease, as well as tuberculosis, sexually transmitted infections, and inflammation of female pelvic organs. They also were hospitalized more frequently for conditions that often can be avoided by adequate primary care, such as asthma, epilepsy/convulsions, fluid and electrolyte disorders, problem pregnancies, and chronic skin ulcers.

On the other hand, white patients had more hospitalizations for mental illnesses, circulatory disorders, gastrointestinal conditions, and musculoskeletal conditions, such as osteoporosis and osteoarthritis. Certain types of cancer were more common among white patients: melanoma and other skin cancers, bladder cancer, and cancer of the brain and nervous system. However, cancer of the stomach and esophagus and multiple myeloma were more common among black patients.

Whites were more likely to be admitted for injuries such as joint disorders and fractures of the neck or hip, whereas black patients were more apt to be admitted for open wounds and burns. Finally, hospitalization increased overall during the 8 years studied—but at a sharper rate for blacks—for drug disorders, ischemic heart disease, congestive heart failure, and device or procedure complications.

Ethnicity affects individual and family roles in terminal illness

In France, Spain, Japan, and Eastern Europe, physicians rarely tell patients with cancer their diagnosis or prognosis, usually informing the family instead. In stark contrast, physicians in the United States tell patients the truth about terminal illnesses and involve them in decisions about withholding life support. However, this viewpoint is not held by some ethnic groups in the United States, according to a study supported by the Agency for Health Care Policy and Research (HS07001).

Leslie J. Blackhall, M.D., M.T.S., of the Pacific Center for Health Policy and Ethics, and colleagues, report that Korean-Americans (47 percent) and Mexican-Americans (65 percent) are significantly less likely than European Americans (87 percent) and African-Americans (88 percent) to believe that a patient should be told the diagnosis of metastatic cancer and are less likely to believe that the patient should make decisions about the use of life-supporting technology (28 percent and 41 percent vs. 60 percent and 65 percent). Instead, most Korean-Americans (57 percent) and many Mexican-Americans (45 percent) believe that the family should make decisions about the use of life support.

Physicians should ask their patients if they wish to receive clinical information and make decisions or if they prefer that their families handle such matters, explains Dr. Blackhall. The researchers surveyed 800 elderly residents at 31 senior citizen centers in Los Angeles County as part of a larger study examining the attitudes of older Americans of varying ethnicity toward health care and medical decisionmaking.

Their survey also showed that, within Korean-American and Mexican-American groups, older persons and those with lower socioeconomic status tended to be opposed to telling patients the truth and patient decisionmaking even more strongly than their younger, wealthier, and more highly educated counterparts. Also, more acculturated Mexican-Americans were more likely to share the patient autonomy model with the European-American and African-American subjects.

See "Ethnicity and attitudes toward patient autonomy," by Dr. Blackhall, Sheila T. Murphy, Ph.D., Gelya Frank, Ph.D., and others, in the September 13, 1995 Journal of the American Medical Association 274(1), pp. 820-825.

Medicaid reimbursement and malpractice premiums do not determine which rural family doctors deliver babies

By 1988, the number of rural family physicians providing maternity care had declined to 43 percent, a 23 percent decline since 1980. Contrary to what family physicians often claim, this decline was not associated with high malpractice premium costs—which are about three times higher for family physicians who deliver babies—or low Medicaid reimbursement rates. Rather, the features of their practices and communities were the best predictors of whether they provided maternity care, according to a study supported by the Agency for Health Care Policy and Research (HS06544).

University of North Carolina researchers surveyed 338 family physicians, who moved to rural practices in various States during the late 1980s, to explore the factors associated with the likelihood of these physicians providing maternity care. The researchers constructed their sample from the American Medical Association's Physician Masterfile and used other data sources to find out Medicaid reimbursement rates, malpractice premium costs, and community and practice characteristics.

Results showed that 45 percent of family physicians had performed routine deliveries and provided prenatal care during the preceding 12 months or final year of the first small-town practice in which they worked from 1986 through 1990. Family physicians were more likely to provide maternity care if they were more recently trained, fulfilling service obligations, working in group practices, or working in less populated counties with fewer obstetricians, where their services were needed most. State-by-state differences in malpractice insurance premiums and Medicaid reimbursement rates were not associated with family physicians' likelihood of performing deliveries. The researchers conclude that decreasing the cost of malpractice insurance will not influence the number of family physicians who provide maternity care.

For more details, see "Obstetrical practice among new rural family physicians," by Donald Pathman, M.D., M.P.H., and Sarah Tropman, M.P.H., The Journal of Family Practice 40(5), pp. 457-464, 1995.

Study finds AHCPR's depression guideline to be useful for rural primary care practices

Only 29 percent of depressed patients treated by rural family doctors receive a sufficient level of antidepressant medication for a long enough period to meet recommendations set forth in the guideline on depression supported by the Agency for Health Care Policy and Research. Moreover, few depressed patients in rural family practice settings receive psychotherapy from a mental health professional. As a result, only 32 percent of these patients are in remission at 5-month followup, compared with 70 percent of urban patients in a comparable time period, according to a recent study by University of Arkansas researchers.

The researchers, who were supported by the National Institute of Mental Health, screened 631 patients in 21 primary care practices in small towns; they followed 38 patients with major depression for an average of 5 months using the guideline's Depression Outcomes Module. Patients who received the medications recommended by the AHCPR guideline showed greater symptom improvement at followup. Even though about 63 percent of patients received a prescription for one or more antidepressants between the index visit and followup, only about 29 percent received pharmacologic treatment in accordance with the AHCPR guideline. Approximately 68 percent of the patients continued to meet criteria for major depression at 5 months.

According to study leader Kathryn Rost, Ph.D., of the University of Arkansas for the Medical Sciences, this study has three major findings:

• The process and outcomes of care for major depression appear to be worse in rural family practice settings than in some urban practices. Even with a broad definition of detection, rural family physicians detect only 24 percent of depressed cases at the initial visit.
• The AHCPR-supported depression guideline represents a straightforward treatment plan for improving outcomes among rural populations.
• The Depression Outcome Module presented in the guideline appears to be a valid and reliable instrument for use in the primary care setting to evaluate the process and outcomes of care for major depression.

For more details, see "The process and outcomes of care for major depression in rural family practice settings," by Dr. Rost, Carla Williams, B.A., Jeff Wherry, Ph.D., and G. Richard Smith, Jr., M.D., in The Journal of Rural Health 11(2), pp. 114-121, 1995.

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