A new study “convincingly” demonstrates racial and ethnic disparities in outpatient neurologic care in the United States and highlights the need to characterize and address barriers to neurologic care, researchers say.
The study showed that blacks and Hispanics are less likely to have an office visit with a neurologist than whites in the US. Blacks with neurologic conditions such as Parkinson’s disease (PD) and stroke are more apt to be cared for in the hospital emergency department (ED) and had more hospital stays than whites, the study found.
“These disparities are concerning not only because racial and ethnic minorities represent 28% of Americans, but because all Americans should have equitable access to health care regardless of who they are, where they live, or what resources they have,” the researchers say.
“Disparities in neurologic care are something for the entire field of neurology, and for all neurologists, to contend with and address,” first author Altaf Saadi, MD, from Massachusetts General Hospital and Brigham and Women’s Hospital in Boston, told Medscape Medical News.
The study was published online May 17 in Neurology.
A Problem For All
Dr Saadi and colleagues analyzed 8 years of data from the Medical Expenditure Panel Survey (MEPS), including information on demographics, patient-reported health conditions, neurology visits, and costs. Using diagnostic codes, they identified individuals with any self-identified neurologic disorder (except back pain) as well as five subgroups (PD, multiple sclerosis [MS], headache, cerebrovascular disease, and epilepsy).
Of the 279,103 MEPS respondents, 16,936 (6%) reported a neurologic condition, including 3338 with cerebrovascular disease, 2236 with epilepsy, 399 with MS, and 397 with PD, plus other less common neurologic conditions.
Altogether, 5890 individuals made 13,685 outpatient visits to neurologists.
Compared with whites, blacks were nearly 30% less likely to have an outpatient visit with a neurologist (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.64 – 0.81) after adjusting for demographic, insurance, and health status differences. Hispanics were 40% less likely to see an outpatient neurologist (OR, 0.61; 65% CI 0.54 – 0.69).
Blacks with neurologic conditions were more likely to receive care in a hospital ED, with 12.6 ED encounters for every 100 people for blacks, 7.7 ED encounters for Hispanics, and 7.7 ED encounters for whites. Blacks also had more hospital stays than whites, with 9.4 inpatient stays for every 100 people for blacks, 4.7 stays for Hispanics, and 4.5 stays for whites.
Blacks also had higher hospital costs of $1485 per capita compared with $599 for whites.
Asians and those of other races or mixed race were not included in the analysis because patenumber of people involved was too small to provide accurate statistics, the researchers say.
“Previous research has shown that having neurologists involved in the care of people with neurologic conditions reduces serious side effects and hospitalizations for acute problems,” Dr Saadi said. “So unequal access to outpatient care may be resulting in unnecessary medical and financial costs.”
There are likely multiple factors behind racial/ethnic differences in neurology health care access and utilization, the researchers say, such as different cultural beliefs and attitudes about aging and disease, access to language assistance for people who don’t speak English, and geographic distribution of outpatient neurology services.
“Reducing racial disparities is going to require a multipronged approach. The problem is too complex to have a simple magic bullet,” Dr Saadi said.
“Some of the strategies that hospitals and individual departments can pursue include raising provider awareness of biases that exist in providing medical care, targeting health education outreach to minority communities to increase awareness of neurologic disease and how neurologists can be helpful to their care, and improving the diversity of the neurology workforce and those working in underserved areas,” said Dr Saadi. “On a policy level, advocating for the expansion for health insurance coverage can be helpful in reducing disparities.”
More Granular Data Needed
“There is definitely a lot to unpack in this article,” said John P Ney, MD, MPH, staff neurologist, Edith Nourse Rogers VA Medical Center, Bedford, Massachusetts, and assistant professor, Boston University School of Medicine, who reviewed the study for Medscape Medical News.
“The first issue is that a lower rate of outpatient neurologist visits is not the same as reduced access to neurologists. This paper does not, for example, correlate the density of neurologists in a geographic area with racial or ethnic populations,” Dr Ney noted.
The study also does not appear to control for disease state or burden, he noted. “Notably, African Americans may have a greater incidence of conditions that are taken care of through inpatient care (cerebrovascular disease), rather than outpatient care (MS). This latter point is reflected in higher inpatient costs for African Americans, where stroke costs can be far more expensive. Also, in the models presented, there is not an attempt to control for comorbid conditions, which is a limitation of the paper,” said Dr Ney.
“Certainly, this study raises interesting questions that could be furthered by more granular research involving availability of neurologist outpatient care in minority communities and attitudes toward specialist physicians and neurologists among racial and ethnic minorities,” Dr Ney added.
“This study did not look at overall outcomes of care, which would be another very important avenue for future research. More funding to address issues of disparities in access to care and outcomes is needed,” Dr Ney concluded.
The study authors have disclosed no relevant financial relationships.
Neurology. Published online May 17, 2017. Abstract
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