Assessing Potential Sources of Racial and Ethnic Disparities in Care: Patient- and System-Level Factors

The literature reviewed earlier in this report demonstrates that evidence of racial and ethnic disparities in healthcare is persuasive and remarkably consistent across a range of health conditions and procedures, and cannot be fully explained by differences in access to care, such as insurance status. Moreover, the literature suggests several sources for these disparities. This evidence, however, does not suffice for an authoritative, comprehensive, unambiguous account of how disparities arise. A number of uncertainties confound efforts to synthesize what is known empirically about stereotypes and prejudice, doctor-patient relations, clinical judgment and patient preferences, as well as the social, institutional, financial, and legal forces that shape the practice of medicine. Yet an effort at such a synthesis is essential to construct an evidence-based account of how disparities in care emerge, and of what might be done to eliminate these disparities. To begin, this chapter presents a model of how disparities might occur. This model builds upon the wide foundation of empirical evidence but makes reasoned inferences when they are necessary to explain observed disparities. The committee makes such inferences when, in our judgment, they are more probable than not and when practical consequences, in the form of recommended actions to ameliorate known disparities, follow from these inferences. In doing so, the committee acknowledges that gaps in our understanding about causation remain and that further research has the potential to enhance understanding. The chapter then presents a review of empirical literature that raises hypotheses regarding potential sources of racial and ethnic disparities in