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Racial and Ethnic Variations in Office-Based Medical Care for Work-Related Injuries and Illnesses Allard E. Dembe, ScD; Judith A. Savageau, MPH; Benjamin C. Amick 111, PhD; and Steven M. Banks, PhD Shrewsbury, Massachusetts and Houston, Texas
Fnancial Supot This research has been supported through CDC/NIOSH Grant #R21-OH07322. Objectives: Thi exploratory study uses notionally representative data to evaluate the extent to which ambulatory care for wokr0lt condiftons vas by patients' race and ethnicity. Methods: Using the National Ambulatory Medical Care Survey (NAMCS) for 1997 and 1998, we descnbe medical care for work-related conditions, stratifying by whether the patent selfidentified as African-Amercan, white, Hispanic and/or non-Hispanic. Multivariate regression analyses were conducted to evaluate the impact of patient race and ethnicity on care, controlling for age, gender, geogrphical region and MSA (urban/rural) status. Results: Compared to white patients,-African-American patients were more likely to receive mental health counseling and phical therapy and less likely to see a nurse, after controlling for age, gender, geographical region and MSA status. Hispanic patients were more likely to receive x-rays and need insurer authorization for care and less likely to receive a prescription drug or to see a physician, compared to non-Hispanics. Conclusions: This is the nation's first study to descrbe socially based differences in medical care provided for patients with work-related injures and illnesses. Identifying areas in which these variations in care exist is a critical first step in ensuring that equitable care is affred to all ijured workers. Key words: occupational medicine * workers' compensation U ambulatory care U race * ethnicity © 2005. From the University of Massachusetts Medical School (Dembe, associate professor; Savageau, assistant professor; Banks, associate professor), Shrewsbury, MA and the University of Texas-Houston School of Public Health (Amick, associate professor), Houston, TX. Send correspondence and reprint requests for J NatI Med Assoc. 2005;97:498-507 to: Allard E. Dembe, ScD, Associate Professor and Senior Research Scientist, Center for Health Policy and Research, University of Massachusetts Medical School, 222 Maple Ave., Higgins Building, Shrewsbury, MA 01545; e-mail:
[email protected]
498 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Considerable progress has been made in identifying distinctive patterns of medical care among racial and ethnic groups in the general healthcare setting."-3 However, relatively little is known about how medical care for workers suffering occupational injuries or illnesses varies according to patients' race and ethnicity. In this article, we report the results of an exploratory analysis of a nationally representative sample of office-based medical visits to provide descriptive information about characteristic patterns of ambulatory care for treatment of work-related conditions among African-American and white patients and among patients of Hispanic and non-Hispanic ethnicity. Previous studies have indicated that the incidence of workplace injuries and illnesses varies according to workers' sociodemographic characteristics. The existing evidence suggests that ethnic and racial minorities, the poor, immigrants and migrant workers are especially vulnerable to occupational injuries and illnesses. For example, studies have found that African-American and Hispanic workers have elevated rates of workplace accidents compared to whites and non-Hispanics,4-9 and immigrant workers account for a disproportionate share of workplace fatalities.'0 Authorities have offered several possible explanations to account for observed disparities in the incidence of work-related injuries and illnesses: minority workers are employed in riskier jobs; certain groups of workers may have elevated hazard exposures within a particular job classification; differing environmental or behavioral risks among social groups; racism and discrimination in supervisory practices; and underlying differences in socioeconomic conditions (e.g., housing, education, nutrition) among subpopulations of workers."'-'4 Despite the growing recognition of socially based variations in the incidence of occupational injuries and illnesses, researchers have not yet investigated whether there are differences in medical care forjob-related disorders based on patients' race and ethnicity. A few anecdotal reports have suggested that some injured VOL. 97, NO. 4, APRIL 2005
RACIAL AND ETHNIC VARIATIONS IN CARE
employees may experience significant barriers in obtaining prompt and appropriate care for job-related ailments, and that minorities, low-wage, immigrant and migrant workers face the most serious difficulties."5 For example, among a group of low-wage, predominantly female garment workers in New York City, it was reported that nonwhites were more likely than whites to have their claims for occupational carpal tunnel syndrome disputed by workers' compensation insurers, resulting in lengthy delays in accessing medical treatment.'6 In a recent survey of injured workers in California, Spanish-speaking, nonwhite and low-income respondents reported significantly lower satisfaction with the doctor-patient interaction during treatment.'7 Despite these isolated reports, the scientific study of socially based differences in occupational medical care is still in its infancy. To date, there have not been any systematic research findings published on this topic. The absence of published research in this area may reflect a belief that the comprehensive workers' compensation coverage provided to almost all American workers by their employers assures equal opportunity to appropriate medical care. Also, research data have been difficult to obtain, partly because workers' compensation insurance claims records often do not
contain information about the claimant's race, ethnicity or nationality. In this article, we derive nationally representative estimates for various dimensions of office-based medical care for patients with workrelated injuries and illnesses, examining specifically whether care varies according to whether patients are African-American, Hispanic or white.
MATERIALS AND METHODS Data and Sample
The National Ambulatory Medical Care Survey (NAMCS) is a nationally representative survey of physicians providing office-based ambulatory medical care in the United States. The survey has been conducted annually since 1973 by the National Center for Health Statistics (NCHS) of the U.S. Centers for Disease Control and Prevention. The target universe of the NAMCS includes ambulatory visits made to offices of nonfederally employed physicians, excluding visits made in hospital-based settings and care provided by anesthesiologists, radiologists and pathologists. Each physician is asked to complete a patient record for a random sample of visits occurring during a randomly assigned oneweek period. Information is recorded by the Table 1. Patient Demographic Characteristics, by Patients' Race/Ethnicity, Office regarding physician Visits for Work-Related Conditions, Weighted Percent Distribution (n=1,179) the patient's demographic characterisHispanic Ethnicity Patient Race White Hispanic Non-Hispanic African-American tics, symptoms, diagnosis and the medical Proportion of all visits for services, tests, med83.7 18.7 81.3 work-related conditions 11.9 ications and procedures provided during Age the visit. In addition, 0.7 0.5 0.8 0.2
