Brown Research: Racial Bias in Nursing Homes

Wednesday, October 12, 2011

Kalena Crafton, GoLocalProv Contributor

nursinghomeracial

Are white nursing home patients getting better care than black patients?

At the beginning of the 2011-12 flu season, a Brown University study has revealed that black nursing home residents are less likely than their white counterparts to receive flu shots. Overall, vaccinations have yet to reach the 90 percent level sought by Medicare and Medicaid.

The study finds that the proportion of nursing home patients who get a shot remains lower than a national public health goal, and that the rate is lower for blacks than for whites. The disparity persists even within individual nursing homes, said the Brown researchers who investigated the disparity and some of the reasons behind it.

Disparity in care, disparity in facilities

“One reason you would potentially see a difference is that blacks and whites are by and large served by different nursing homes and there’s lots of evidence to suggest that blacks are served in nursing homes that are not as good,” said Vincent Mor, professor of health services policy and practice at Brown and senior author of the study published in the October issue of Health Affairs. “However, we also see a pretty persistent difference within the same homes, although it is not as large and it has lessened over time.”

In the study, a team led by Brown community health investigator Shubing Cai looked at hundreds of thousands of patient records from more than 14,000 nursing homes each year between the 2006-07 and 2008-09 flu seasons.

Percentages reveal the gap

The National Institute on Aging helped fund the research which found that the overall vaccination rate in the latest year is 82.75 percent, short of the 90 percent goal set by Medicare and Medicaid. For whites this rate was 83.46 percent, while for blacks it was 77.75 percent. The rates for both races were slightly higher than in 2006-2007 when whites had a rate of 82.62 percent and blacks saw a rate of 75.42 percent.

When the team analyzed the relative risk of going unvaccinated, they found that while the disparity is dropping overall, it remains significant even within the same homes where service quality and staffing levels are presumably the same for blacks and whites. In 2008-09 blacks overall were about 23 percent less likely than whites to be vaccinated and about 15 percent less likely to be vaccinated as their white neighbors within the same home.

Reasons behind the numbers

Much, though not all, of the reason why blacks receive fewer vaccinations is because they turn them down more often, Cai said. According to the records, black patients refused vaccinations in 12.88 percent of cases in 2008-09, accounting for more than half of the situations where no vaccination occurred. Whites only turned down vaccines at a rate of 8.93 percent.

The higher rate of refusal among blacks declined over time, but didn’t fully explain the disparity within a facility, Cai said. “After we dropped patients who declined offers from the analysis, we still saw a difference within facilities,” she said. Blacks were less likely to be offered vaccines.

“We did not have data to examine why blacks are more likely to turn down the vaccine or why nursing homes are less likely to offer vaccines to blacks," said Cai. "As suggested by other studies, it may be related to blacks' perceptions and beliefs about flu vaccines.

Cai said that enhancing the communication between nursing home staff and black residents or providing education program target at black residents/their family may change black residents' knowledge regarding safety and effectiveness of the flu vaccination, and increase their acceptance of flu vaccines.

How to narrow the gap

Finding the single best way to resolve the disparity may well require interventions to determine what mix of factors are afoot in individual homes, Mor said. One question worth further study, he said, is whether the higher rate of vaccine refusal among black patients perhaps reflects how the vaccines are being offered.

“The way to address the within-facility disparity is to find out why there are these refusals and determine better ways of communicating the vaccine’s benefits that specifically addresses patients’ reluctance and refusal,” he said.

In addition to Cai and Mor, the paper’s other authors are Brown sociologist Mary Fennell and gerontologist Zhanlian Feng. To view the study, go here.