Race may influence quality of autism care

Race may influence quality of autism care
Race may influence quality of autism care

Disparities exist in the quality of subspecialty care non-white patients with autism receive, results of a recent study suggest.

Black, Hispanic and other non-white children were 38% to 68% less likely to see specialists for gastrointestinal and nutrition services, neurology and psychiatry or psychology services than white patients, Sarabeth Broder-Fingert, MD, of Boston's Massachusetts General Hospital for Children, and colleagues reported in Pediatrics.

Overall, 37% of white and Hispanic children received care from a subspecialist compared with 30% of blacks, they found.

Previous studies have shown minority children receive later diagnoses, experience delays in getting critical mental health services and have difficulty receiving care, despite similar incidence of ASDs across racial and ethnic groups.

Furthermore, many children with ASDs experience comorbidities, including anxiety or ADHD (30%), trouble sleeping (40% to 80%), gastrointestinal problems (17% to 85%) and epilepsy (5% to 38%).

To better understand whether disparities exist in the quality of care patients receive for these comorbidities, Broder-Fingert and colleagues analyzed records from 3,615 patients aged 2 to 21 years with an autism spectrum disorder (ASD) who received care at Massachusetts General Hospital or its affiliate health centers between January 2000 and January 2011. 

Patients with Asperger Syndrome were not included in the study, as this diagnosis is less stable and more likely to be reevaluated as a different neurological condition over time. Overall, 7% of participants were Hispanic, 5% were African American and 7% had other non-white backgrounds.

Procedures studied were broken down into three categories: gastroenterology (GI)/nutrition, neurology and psychiatry/psychology. These subspecialties were then again divided into even more specific procedures, such as pH probes and endoscopies for GI/nutrition, electroencephalography (EEG) and sleep studies within neurology, and psychiatric and developmental testing for psychiatry/psychology.

Across the board, white patients received more medical attention, but particularly for GI and nutrition procedures, the researchers found. Compared with white kids, the odds of seeing a GI or nutrition subspecialist were significantly lower at 0.32 for both blacks and Hispanics and 0.56 for other nonwhite race/ethnicity.   

For neurology procedures, both blacks and Hispanics were about half as likely to receive a test compared with whites (OR=0.52, 0.40, respectively).

For psychology/psychiatry visits, ORs were 0.44 for African Americans, 0.60 for Hispanics, and 0.62 for others compared with whites in the study. 

When the researchers analyzed the likelihood of specific procedures by race and ethnicity, certain tests were prominently one-sided. In particular, white patients (13.8% ) were two to three times more likely than African-American (4.3%) or Hispanic patients (5.8) to get colonoscopies and endoscopies (18.2% vs. 9.6% and 8.6%, respectively). 

Notably, Hispanics were less likely to undergo testing for neurologic comorbidities compared with whites, with odds that were 47% lower for EEG, 38% lower for brain MRI, 82% lower for sleep studies and 47% lower for neuropsychiatric testing. Blacks also had 67% lower odds of undergoing a brain MRI than whites.

It is possible that these findings simply represent deviating medical patterns between races, the researchers acknowledged, for example autistic white children more often have GI issues that necessitate more relevant procedures for these conditions.

However, external factors may also play a role -- clinicians providing more or less appropriate care based on racial biases. Consequently, “it is possible that in our population white patients with ASDs receive care beyond the basic standard care, whereas nonwhite children receive only the minimal care necessary,” the researchers wrote.

They proposed several potential solutions to address racial disparities in ASD care. These include encouraging broader communication between black and Hispanic patients and clinics to keep families informed and active, and  more scrupulous medical practices and diligent education about appropriate procedures on the part of health providers to limit clinician bias.

by Walker Harrison, an undergraduate student at Columbia University and editorial intern with Clinical Advisor.

References

  1. Broder-Fingert S et al. Pediatrics. 2013; doi:10.1542/peds.2012-3886.
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