Racial Disparities in the Quality, Cost of Care for Medicare Beneficiaries With Localized Prostate Cancer
Black men who receive radical prostatectomy experienced longer wait times, higher costs, and poorer quality care than white men.
Black men with localized prostate cancer are more likely to receive poorer quality care, experience more adverse events, and incur higher costs than white men, although this does not translate to increased cancer-specific or all-cause mortality.1
Using Surveillance, Epidemiology and End Results (SEER) and Medicare claims data, Quoc-Dien Trinh, MD, of Brigham and Women's Hospital, Harvard Medical School, Boston, MA, and coauthors investigated disparities in quality of care and survival rates of non-Hispanic white and black men who underwent radical prostatectomy between 1992 and 2009.
“The quality of care for men of African origin undergoing surgery is not as good as in white patients according to the metrics that we measured,” said Dr. Trinh in an interview with Cancer Therapy Advisor. “The other conclusion is that at least when you have men who have access to care, on Medicare, who actually make it to the operating table, there's no difference in survival between men of African origin and non-Hispanic whites.”
The authors found that the proportion of black men who underwent radical prostatectomy was 59.4%, compared with 69.5% of whites; that black men had a 7-day treatment delay compared to white men in the top 50% of patients; that black men were less likely to undergo lymph node dissection, but had higher odds of postoperative visits to the emergency department than whites; and that surgical treatment of black patients was associated with a higher incremental annual cost than that of whites. The authors found no difference in prostate cancer-specific mortality or all-cause mortality between black and white patients.
“Ultimately I think we need major policy changes to address these disparities,” said Dr. Trinh. “We're building things like Accountable Care Organizations…yet for all that we're saying, there are no clear incentives to reduce disparities. I would like to see someone say that now, as a quality metric, we expect the same survival or the same level of treatment between African-American and white patients for this cancer.”
Dr. Trinh said that raising awareness of health care disparities at a local level is also important. “There may be racial biases between providers, and we need to be aware of these biases and what we need to do to make things better,” he said. “But at the same time if we make major policy changes then maybe we'll see a drastic improvement.”
Commentary: “Clear Evidence” of Racial Disparities
In an invited commentary, Otis W. Brawley, MD, MACP, of the American Cancer Society and Emory University, Atlanta, GA, wrote “[t]his is an ethical issue. This is an issue of social injustice and a very unsettling point. Adequate high quality care for all, regardless of race and social status, should be a priority for medicine and for society in general if this country is to reach its maximal potential.”2
Dr. Bradley also noted the irony that “unequal treatment leads to equal outcomes,” and wrote that this may indicate that radical prostatectomy may be over utilized in treating Medicare-age patients.
“This study reaffirms something that has been seen time and time again over the last 25 years,” said Dr. Brawley in an interview with Cancer Therapy Advisor. “People who are categorized as black or African-American as a group are less likely to get optimal care.”
“I think the problem in the United States is that health care is by and large still racially segregated,” said Dr. Brawley. “And the…providers who take care of black patients are either overwhelmed and cannot provide quality of service, or they may not be as well trained” as those who see white patients.
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Dr. Brawley also said he thinks disparities may be compounded by a lack of access to specialists. “The paper did find some evidence to suggest that part of the issue was doctors who take care of a lot of minority patients don't have the opportunity to specialize in the treatment of prostate cancer,” he said, “whereas whites overwhelmingly end up going to doctors who do a lot of prostate cancer treatment.”
Dr. Trinh agreed. “It's not only about accessing care in general but also about who you are seeing,” he said. “African-American men with prostate cancer don't always see the providers with the most experience.”