Racial Health Disparities in Low-Value Care Call Attention to Bias

A new study from researchers at Brigham and Women’s Hospital, Harvard Medical School, and the Geisel School of Medicine at Dartmouth is calling into question the individual and structural forces that drive racial health disparities in receipt of low-value care.

The data published in BMJ showed that Black patients were modestly more likely to receive low-value acute diagnostic testing, while White people were modestly more likely to receive low-value screening and treatment.

Low-value care is defined as “services that provide little to no benefit in specific clinical scenarios yet have potential for harm,” the researchers wrote, and it can have detrimental impacts on individual patient health and health system operations.

Low-value care, which includes unnecessary treatments or testing, can increase exposure to patient harm, increase rates of false positives, and be extremely costly. Moreover, it can siphon resources from hospitals and health systems, potentially diverting care from individuals who need it.

In an assessment of nearly 10 million patients, researchers tracked the prevalence of 40 low-value services.

Overall, Black patients were more likely to receive low-value diagnostic testing. For example, around 7 percent of Black patients received imaging for uncomplicated headaches, compared to about 3 percent of White patients. Receipt of low-value diagnostic testing among Black patients was between one and twofold higher than for White patients, the researchers said.

Conversely, White patients were more likely to receive low-value screening and treatment. For example, while 10 percent of White people had preoperative laboratory tests, 6.5 percent of Black patients underwent the same. Adjusted differences in receipt of low-value treatment, like antibiotics for upper respiratory infection, were smaller: 36.6 and 32.7 percent for White and Black patients, respectively.

These figures may not appear groundbreaking, the researchers acknowledged, but they can provide insights into how sociodemographics and bias can impact healthcare.

“Although the racial differences we found were heterogeneous and generally modest, they varied by low value service category in informative ways,” the researchers said. “These patterns suggest hypotheses about possible mechanisms at individual, interpersonal, and structural levels that can inform low value care reduction efforts more broadly.”

For example, limited patient trust among Black populations could be behind the slightly greater risk for low-value acute diagnostic tests, the researchers said. Because this population tends to report lower trust in medical providers, they may be more likely to agree to diagnostic testing because it is more reassuring than a provider’s assessment.

On the provider side, implicit or explicit biases could also impact communication, which in turn could result in misunderstandings of patient care needs and preferences.

Finally, the healthcare industry at large could perpetuate racial disparities in low-value care by way of limited patient engagement with certain treatment protocols. For example, lower rates of advanced care planning and documented end-of-life preferences among Black people could lead providers to engage with more low-value care that, ultimately, may not align with patient wishes.

Implicit bias and structural racism could also be behind the higher propensity for White people to receive more low-value screenings and low-value treatments, such as antibiotics for upper respiratory infections.

The researchers said foremost, this higher rate of low-value screening or treatment could be due to more White people requesting these services. The trend could also reflect lower access to routine primary care among Black patients.

“Unfortunately, lower rates of low value screening among Black patients parallels lower rates of high value screening, such as age appropriate colorectal cancer screening,” the researchers said.

“Taken together, these results invite further exploration of differential access by race to routine, high value primary care, patient-clinician concordance, and trust,” they concluded. “Our findings also highlight the need to develop and test effective interventions to reduce low value services, especially those with greatest potential impact (ie, based on numbers of people affected, direct and cascading costs, and likelihood of other harms).”