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Differences access and quality of care. Health outcomes, whether measured by relative incidence of death, disease, or disability, are disproportionately unfavorable among minority elders (Agency for Healthcare Research and Quality, 2002). African Americans experience more hypertension, cardiovascular disease, stroke, and end-stage renal disease than white Americans (Birrer, 1992; Barnett et al., 2000, 2001; Wassertheil-Smoller et al., 1979). In addition, African Americans have an increased incidence of certain cancers and have lower overall five-year cancer survival rates (Ansell et al.,1993; Centers for Disease Control, 2002; Gordon et al., 1992; Cella et al., iggi; Moul et al., 1995). Type 2 diabetes disproportionately affects African Americans, Hispanics, and Native Americans (Harris et al., 1987). One consequence of the disparities disease rates is a more rapid decline functional status with advancing age of African Americans compared to older whites (Miles and Bernard, 1992). In contrast, whites and Asian Americans have higher rates of osteoporosis and osteoporosis-related fractures (Farmer et al., 1984; Bauer,1988). Even more alarming are data demonstrating differences access and quality of care for white versus nonwhite patients. Disparities healthcare delivery access and quality of care are well documented. Important differences exist among racial and ethnic groups the probability of receiving any healthcare, as well as the probable use of specific services, such as inpatient hospital care (Fiscella et al., 1998). Nonelderly minority Americans are at least twice as likely to be uninsured as whites. Latinos are the most likely to be uninsured, with about one third uninsured 1997. Undoubtedly, this lack of access throughout life affects the morbidity and mortality rates late life. A recent report of the Institute of Medicine (toM) concluded that racial and ethnic minorities the United States receive a lower quality of care than whites (IOM, 2002) after accounting for differential access to care. The report stated that, in examining the roots of these disparities, the committee is struck by the fact that the sources are complex and multifactorial. Included among the factors are clinical uncertainty, stereotypical behavior, and conscious bias that may extend all the way to prejudice. The findings of the Commonwealth Fund's 2001 Health Care Quality Survey also demonstrate that minority Americans do not fare as well as whites on a wide range of measures of health quality (Collins et al., 2001). These disparities are evident across chronic disease categories, which disproportionately affect older adults. The relationship of putative reasons for disparities, adapted from models of community health (Andersen, 1995), are illustrated Figure I. Individual factors include genetic endowments; ethnicity; gender; lifestyle factors such as diet, exercise, and substance abuse; health literacy; access to information; income and education; insurance status; differential definitions or perceptions of illness and health; and alternative help-seeking behaviors. Provider factors include such issues as bias, culture, and ineffective communication. Environmental factors include racism and community-based factors such as social cohesion, neighborhood structures, and organizations. Health system factors include the organization, financing, and distribution of health services. Figure helps clarify the relationship between health outcome disparities and healthcare disparities. Clearly, healthcare disparities can cause or exacerbate disparities health outcomes. However, health disparities are also influenced by individual, social, environmental, and other factors external to the process of healthcare. Health disparities healthcare delivery may reflect deeply held individual or cultural preferences. We must consider the overriding impact of community, social, and environmental factors on all others. …
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