Instrumentación para el proceso de pesaje

Traditionally, research regarding racial disparities in health has followed two ideological and moralistic tracks concerning sources of disparities. These tracks include 1) identifying the tendency of blacks to have faulty individual behaviors, such as risk factors like illiteracy, smoking or obesity, and 2) blaming social causation, such as racial discrimination and bias in access to and delivery of the system (Mechanic, 2001, page 2). More recent studies have shown that this moralistic and ideological orientation was a convenient excuse to focus the research agenda on prevalence of racial health gaps. Analyzing health care practice devoid of morality and ideology is the new target for disparities research, with a focus on racial variation as opposed to racial bias (Horner et al., 2004, Rathore & Krumholz, 2004). If risky behavior was the only issue with respect to disparities then black and white smokers should realize the same health outcomes. If access was the only issue then low- income persons with Medicaid, regardless of race, should have better health status since theirs is one of richest benefit plans in the current health care system (Cooper, 2007).

Refining research to identify sources and causes of health disparities is not an easy task. Health care practices are complicated, especially with respect to

understanding the extremes in racial differences in access and treatment. Both too little health care for blacks to address some chronic conditions and too many aggressive treatments for blacks to address acute conditions have been observed. Consider, for example, cardiovascular disease, the number one cause of death in the United States. Even rigorous studies (i.e. controlling for disease severity that might be caused by individual poor health habits or proportionally greater use of clinical services by whites that might result from socially acceptable discrimination and bias in health care access against minority groups) show less aggressive diagnosis and medical treatment of blacks than whites for chronic heart disease (Smedley et al., 2003). In contrast, blacks are more likely than whites to receive aggressive treatment options such as amputation to treat diabetes that produces acute conditions resulting from poor circulation (Gornick et al., 1996). Thus, racial disparities in health care is not just an issue of too little care or access for blacks compared to whites. More treatment is not necessarily better health care; the target for improved quality of care is determining the best treatment options specific to the patient’s individual

circumstances including race and ethnicity (Gornick et al., 1996). This is a new paradigm for the fundamental clinical decision-making process.

The clinical decision process has understandably become a target of inquiry about sources of racial disparities in health. Treatment decisions are primarily within the purview of patients and their providers and are usually affected by broader social issues such as individual patient and provider tendencies and preferences and the underlying social stigma against minorities (Beach et al., 2007). As such, the patient- provider relationship and communication in its many dimensions of clinical

encounters is considered a primary source of racial disparities in health (Horner et al., 2004). Physicians face time and resource pressures and their training encourages stereotyping of symptoms (known as heuristics) to make diagnoses that have been shown to produce treatment recommendations that replicate provider prejudice and lack of cultural sensitivity to patient circumstances (Balsa et al., 2007, Smedley et al., 2003, van Ryn & Burke, 2000). Patients, especially those in vulnerable populations who are less trustful of providers, do not always provide needed information and ten d to be less compliant with treatment recommendations (Barski et al., 1980, Halbert et al., 2006, Hall et al., 2002, Heisler et al., 2005, Russell & Conn, 2005).

Patient-centered care or care that involves the patient in negotiation of treatment based on individual characteristics is designed to overcome the overcome patient-provider trust issues and stereotype-laden dependence of clinicians on probability and prior beliefs (Balsa et al., 2007, Trachtenberg et al., 2005). Patient- centered care15 redirects provider decision-making from time and information limited biases and prior beliefs to a new focus on patient empowerment through provider: a) respect for patient preferences and involvement in decision-making; b) access to care; c) coordination of care; d) information and education; e) physical comfort; f)

emotional support; f) involvement of family and friends; and g) continuity of care (Cronin, 2004, Gerteis, 1993, Shaller, 2007).

Patient-centered care is a popular solution to racial disparities in health

outcomes because it creates a new paradigm for health care provider decision making when the traditional clinical decision-making paradigm has been shown to be

grounded in racial stereotypes and unconscious bias based on prior beliefs of the

provider and the lack of trust by vulnerable patients (Fiske, 1998, Halbert et al., 2006, Smedley et al., 2003, Trachtenberg et al., 2003). The logic for PCC as a solution to racial disparities in health outcomes is as follows: a) patient-centered care is better quality care; b) patient-centered care counters traditional clinical decision-making techniques that include biases and stereotypes so it must result in less disparate treatment decisions; c) patient-centered care empowers the patient which mitigates trust issues with the providers; d) treatment decisions affect health outcomes; and e) therefore because patient-centered care improves treatment decisions, then patient- centered care must be a solution to racial disparities in health.

Patient-centered care is the popular new paradigm. Given the abysmal performance of the current health care delivery system, new paradigms are often treated as solutions rather than subjects of investigation; they are often implemented first and then investigated later for their impact (Kleinke, 2001, Sepucha et al., 2004).