Kressin Nancy R, Groeneveld Peter W
VA Boston Healthcare System; Boston University School of Medicine.
Milbank Q. 2015 Mar;93(1):112-38. doi: 10.1111/1468-0009.12107.
POLICY POINTS: Racial/ethnic differences in the overuse of care (specifically, unneeded care that does not improve patients' outcomes) have received little scholarly attention. Our systematic review of the literature (59 studies) found that the overuse of care is not invariably associated with race/ethnicity, but when it was, a substantial proportion of studies found greater overuse of care among white patients. The absence of established subject terms in PubMed for the overuse of care or inappropriate care impedes the ability of researchers or policymakers to synthesize prior scientific or policy efforts.
The literature on disparities in health care has examined the contrast between white patients receiving needed care, compared with racial/ethnic minority patients not receiving needed care. Racial/ethnic differences in the overuse of care, that is, unneeded care that does not improve patients' outcomes, have received less attention. We systematically reviewed the literature regarding race/ethnicity and the overuse of care.
We searched the Medline database for US studies that included at least 2 racial/ethnic groups and that examined the association between race/ethnicity and the overuse of procedures, diagnostic (care) or therapeutic care. In a recent review, we identified studies of overuse by race/ethnicity, and we also examined reference lists of retrieved articles. We then abstracted and evaluated this information, including the population studied, data source, sample size and assembly, type of care, guideline or appropriateness standard, controls for clinical confounding and financing of care, and findings.
We identified 59 unique studies, of which 11 had a low risk of methodological bias. Studies with multiple outcomes were counted more than once; collectively they assessed 74 different outcomes. Thirty-two studies, 6 with low risks of bias (LRoB), provided evidence that whites received more inappropriate or nonrecommended care than racial/ethnic minorities did. Nine studies (2 LRoB) found evidence of more overuse of care by minorities than by whites. Thirty-three studies (6 LRoB) found no relationship between race/ethnicity and overuse.
Although the overuse of care is not invariably associated with race/ethnicity, when it was, a substantial proportion of studies found greater overuse of care among white patients. Clinicians and researchers should try to understand how and why race/ethnicity might be associated with overuse and to intervene to reduce it.
政策要点：医疗服务过度使用（具体而言，即对改善患者预后并无帮助的不必要医疗服务）方面的种族/族裔差异很少受到学术关注。我们对文献进行的系统综述（共59项研究）发现，医疗服务过度使用并非总是与种族/族裔相关，但即便存在关联，相当一部分研究发现白人患者的医疗服务过度使用情况更为严重。在PubMed中，缺乏针对医疗服务过度使用或不适当医疗服务的确立主题词，这妨碍了研究人员或政策制定者整合先前的科学或政策成果。
关于医疗保健差异的文献研究了接受必要医疗服务的白人患者与未接受必要医疗服务的种族/族裔少数群体患者之间的对比情况。而医疗服务过度使用方面的种族/族裔差异，即对改善患者预后并无帮助的不必要医疗服务，受到的关注较少。我们对有关种族/族裔与医疗服务过度使用的文献进行了系统综述。
我们在Medline数据库中搜索了美国的研究，这些研究至少纳入了两个种族/族裔群体，并考察了种族/族裔与医疗程序过度使用、诊断（医疗服务）或治疗性医疗服务之间的关联。在最近的一项综述中我们确定了按种族/族裔划分的过度使用研究，并且还查阅了检索文章的参考文献列表。然后我们提取并评估了这些信息，包括所研究的人群、数据来源、样本量及构成、医疗服务类型、指南或适宜性标准、临床混杂因素的控制及医疗服务的资金来源，以及研究结果。
我们确定了59项独特的研究，其中11项研究存在方法学偏倚的风险较低。具有多个结果的研究被多次计数；它们总共评估了74个不同的结果。32项研究（6项偏倚风险较低）提供的证据表明，白人比种族/族裔少数群体接受了更多不适当或不推荐使用的医疗服务。9项研究（2项偏倚风险较低）发现少数群体比白人存在更多医疗服务过度使用的证据。33项研究（6项偏倚风险较低）发现种族/族裔与医疗服务过度使用之间没有关系。
尽管医疗服务过度使用并非总是与种族/族裔相关，但即便存在关联，相当一部分研究发现白人患者的医疗服务过度使用情况更为严重。临床医生和研究人员应努力了解种族/族裔可能与医疗服务过度使用相关的方式及原因，并进行干预以减少这种情况。
