Racial Disparities Found in Access to Neurologic Services

Pauline Anderson

April 26, 2017

BOSTON — Studies have highlighted racial disparity in accessing stroke care, but new research suggests that this unequal access to services extends to other areas of neurology, including epilepsy, Parkinson's disease (PD), and multiple sclerosis (MS).

"This is a big problem," lead author, Altaf Saadi, MD, a neurology resident at Brigham and Women's Hospital and Massachusetts Hospital, Boston, told delegates to the American Academy of Neurology 2017 Annual Meeting (AAN).

Solutions for the problem might include addressing implicit biases that exist in healthcare or diversifying the neurology workforce, Dr Saadi suggested.

"Neurologists are often under the impression that we're taking care of everyone with a neurological disease, and I think our study shows that we are not."

As the population ages and diagnostic tools improve, more Americans are being diagnosed with a neurologic disease. At the same time, according to the US census bureau, the percentage of minorities is increasing across the nation.

"Now, about one in three adults will identify as a minority group and by 2050 that will be one in two," said Dr Saadi.

Researchers used the Medical Expenditure Panel Survey, an annual survey of the noninstitutionalized civilian population in all 50 states, and combined years 2006 to 2013. Using International Classification of Diseases codes, they looked for patterns emerging in five neurologic conditions: PD, MS, epilepsy, cerebrovascular disease, and headache.

They study cohort included about 200,000 patients.

Researchers also examined use of, and expenditure for, neurologic services, including outpatient neurologic visits, inpatient hospital stays, and emergency department visits.

They looked at race/ethnicity, age, sex, health insurance coverage, family income, education, and immigration status. As well, they investigated region of care; limitations in activity; and various clinical factors, including self-reported neurologic condition and self-reported health status.

Just over 14,000 Americans received at least one outpatient neurologic visit. Patients making such visits were more likely to be female, older, white, and not an immigrant; to have a higher educational background and higher income; to be on Medicare or privately insured ; and to live in the Northeast.

In terms of clinical factors, these patients were more likely to have PD (56.03% with any neurologist visit; 95% confidence interval [CI], 50.48% - 61.58%), MS (71.36%; 95% CI, 67.10% - 75.61%), or epilepsy (38.29%; 95% CI, 35.47% - 41.11%), have poor or fair overall health, have some limitation in activity, and report poor or fair mental health.

Black and Hispanic patients had significantly lower rates of neurology visits than whites, even after accounting for the various factors, said Dr Saadi. Black adults were 30% less likely to visit a neurologist (odds ratio [OR], 0.72; 95% CI, 0.64 - 0.81), and Hispanic adults were 40% less likely to visit a neurologist (OR, 0.61; 95% CI, 0.54 - 0.69).

These disparities were largest in patients with stroke, and they persisted even after accounting for having a usual source of care. Although having a primary care doctor "was a predictor for seeing a neurologist, it didn't get rid of the disparity, so that's not the whole picture," said Dr Saadi.

These disparities have significant financial ramifications. Compared with whites, minorities were more likely to have emergency department visits, inpatient hospital stays, and higher healthcare expenditures, said Dr Saadi.

As a moderator of this session, Nabila Dahodwala, MD, associate professor, University of Pennsylvania, Philadelphia, addressed Dr Saadi's study during her wrap-up discussion.

Dr Dahodwala noted that race is defined by putting people into "narrow buckets" of place of origin. "But that doesn't account for the fact that people may have mixed heritage, and that the genetic variability within one race is even greater than between races, so I'm not sure what these definitions are capturing."

To illustrate unconscious bias on the part of clinicians, Dr Dahodwala cited a paper in the New England Journal of Medicine (1999;340:618-626) that described presenting cardiologists with four identical cases — same history of chest pain, same electrocardiogram, same physical examination, and so forth — and asking them how they would treat the cases. The only difference was the picture attached to each case; they depicted an older white woman, an older black woman, an older black man, and an older white man.

The blacks and women were less likely to be referred for cardiac catheterization.

Dr Dahodwala stressed that this is not necessarily "overt racism" but that "we have to become more aware of this and improve our education, and try to limit these biases."

Disparities in access to care are not unique to neurology and exist in other medical fields, including cancer, HIV, and asthma, noted Dr Dahodwala.

In neurology, though, there is stigma associated with certain conditions, as well as a degree of uncertainty for some neurologic diagnoses.

"We need to level the playing field," said Dr Dahodwala. "We need to develop programs that are really going to allow everyone to achieve the same — and best —  health possible."

Dr Saadi has disclosed no relevant financial relationships. Dr Dahodwala receives funding from several PD foundations and industry sources.

American Academy of Neurology 2017 Annual Meeting (AAN). Abstract S15.004. Presented April 24, 2017.

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