Racial/Ethnic Disparities in Health Care:

Lessons from Medicine for Dentistry

Nancy R. Kressin, Ph.D.
Abstract: To describe what is known about racial disparities in provided health care and to better understand the dynamics of this
issue within dentistry, this article draws on data from the medical literature, focusing especially on reviewing what is known
about disparities in care received by those who have accessed the health care system. An overview of the possible causal factors
is presented, along with suggestions for future research.
Dr. Kressin is Health Services Research & Development Research Career Scientist, Center for Health Quality, Outcomes, and
Economic Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, and Associate Professor, Health
Services Department, Boston University School of Public Health. Direct correspondence and requests to her at VA Medical
Center, Center for Health Quality, Outcomes, and Economic Research, 200 Springs Road (152), Bedford, MA 01730; 781-687-
2949 phone; 781-687-3106 fax; nkressin@bu.edu.

I
t is a national public health priority to decrease
racial/ethnic disparities in health and health care.
While many of the articles in this special issue
describe disparities in oral health by age, economic
status, race/ethnicity, or other sociodemographic
characteristics, the focus of this one will simulta-
neously be both broader and narrower than the oth-
ers. To broaden the discussion, this article will draw
on data from the medical literature to describe what
is known about racial disparities in provided medi-
cal health care,1 but the latter focus will also narrow
our attention to disparities in care within the health
care system, which are but one possible source of
racial/ethnic disparities in health status. Note that
other articles in this issue2,3 have done an excellent
job of documenting disparities in access to health
care, specifically dental care. This one will focus on
the issue of disparities in care among those who have
already gained access to the health care system, which
is recognizably only a subset of Americans.
Disparities in health and health care have been
recognized as a serious problem for many years.
Under President Clinton, the Department of Health
and Human Services established the Initiative to
Eliminate Racial and Ethnic Disparities in Health,
which targeted specific clinical areas in which to
focus attention.4 These included cardiovascular dis-
ease, diabetes, infant mortality, cancer screening and
management, HIV infection/AIDS, and immuniza-
tions. Also during the Clinton administration, the
surgeon general’s report on “Oral Health in America”
noted that a “‘silent epidemic’ of oral diseases is af-
fecting our most vulnerable citizens—poor children,
the elderly, and many members of racial and ethnic
minority groups.”5,6 More recently, the National In-
stitute of Dental and Craniofacial Research (NIDCR)
of the National Institutes of Health has developed its
own strategic plan to reduce craniofacial, oral, and
dental health disparities (www.nidcr.nih.gov). Thus,
it is clear that disparities in physical and oral health
are on the national radar screen to be addressed, and
disparities in the way health care is provided con-
tribute to disparities in health status, although the
mechanisms and extent of the influence have not yet
been documented.
In 2000, Public Law 106-525 (Minority Health
and Health Disparities Research and Education Act
of 2000) was enacted. This law mandated that the
Institute of Medicine (IOM) study the issue of health
care disparities to develop/summarize the knowledge
base to make it sufficient for Congress to develop
policy from. The law established a new center at the
National Institutes of Health dedicated to issues of
disparities: the National Center for Minority Health
and Health Disparities.
The IOM study produced a landmark report,
“Unequal Treatment,” documenting the ongoing ex-
tensive disparities in health care received, which
occur across a variety of settings and among many
clinical areas, including cardiovascular care, cancer,
diabetes, and renal disease care.1 The report noted
that the evidence of disparities in health care is quite
constant across a myriad of clinical conditions and
settings of care and that the disparities persist even
after applying extensive controls for socioeconomic
differences among patients and patients’ clinical char-
acteristics. Also, the report noted that disparities in
care led to worse outcomes for patients who are not
given appropriate care, an indicator of the serious
implications of such disparities.

998 Journal of Dental Education ■ Volume 69, Number 9

 Unfortunately, disparities in dental care were
not discussed in the IOM report, likely because there
is such a small literature on the topic. Our team re-
cently documented racial disparities in one type of
dental care by examining rates of tooth extraction
versus root canal therapy among insured patients in
the Department of Veterans Affairs (VA) health care
system with a mean age of fifty-seven years.7 We
examined whether racial variations in dental care
exist and whether observed variations in care were a
function of varying levels of insurance coverage for
dental services. Within three different categories of
insurance coverage, we examined whether there were
racial differences in the provision of the preferred,
tooth-sparing treatment of root canal therapy (vs.
tooth extraction) among 54,423 users of outpatient
VA dental care in 1998. We controlled for the sever-
ity of tooth and gum-related disease, age, sex, geo-
graphic region, medical and psychiatric co-
morbidities, prior use of preventive dental services,
tooth extraction, and root canal therapy. In the ad-
justed regression models, we found that African
American and Hispanic patients and those with un-
known race were less likely overall to receive root
canal therapy than whites, while Asians were more
likely. Among patients with eligibility for continu-
ing and comprehensive dental care, African Ameri-
cans and Hispanics were less likely to receive root
canals than whites. For patients covered for only
emergency dental care, there were no racial differ-
ences in the likelihood of receiving root canal therapy.
Among all other types of coverage, only African
Americans remained significantly less likely to re-
ceive this therapy. Thus, these recent data suggest
that racial/ethnic disparities in dental care likely echo
observed trends in medical care, and thus warrant
further study and attention.
Why Do Disparities in
Care Exist?
Numerous possible explanations have been
proposed to answer this question, generally falling
under categories of factors related to the patient, the
provider, the process of interaction between the two,
and the health care system. Figure 1 depicts Kressin
and Petersen’s suggested conceptual model to orga-
nize factors associated with racial disparities in care.8
Patient characteristics that likely influence treatment
decision making include sociodemographic variables
September 2005 ■ Journal of Dental Education
(race, age, income, education, marital status, and
amount or type of health insurance), clinical charac-
teristics (disease burden, disease severity), and
health-related beliefs, attitudes, and preferences for
care. Provider characteristics, including practice spe-
cialty and practice style, attitudes, or bias about pa-
tients, may also influence decision making, as may
aspects of the patient-provider relationship (for ex-
ample, communication and trust). Finally, character-
istics of the health care system in which treatment
decisions are made (availability of necessary tech-
nology and specialty care, organization of services
within the health care system, local practice patterns),
as well as reimbursement and financing issues, must
be considered. Kressin and Petersen8 extensively re-
viewed the literature examining each of these poten-
tial causes of disparities, among studies focused on
invasive cardiac procedure use, perhaps the most
studied clinical situation in the disparities literature.
After reviewing over sixty studies, we concluded that
the field needs comprehensive studies of disparities
that simultaneously include variables from the pa-
tient, the physician, and the health care system, all
of which work together to determine if disparities in
care occur.
Our own comprehensive study of factors asso-
ciated with use of cardiac catheterization has tried to
address this gap in the literature. We examined
whether there were racial differences in cardiac cath-
eterization use among a sample of veterans with
documented reversible cardiac ischemia (making
them potential candidates for cardiac catheterization)
and, if so, to comprehensively examine whether pa-
tient attitudes and beliefs, or physician assessments
or perceptions, could explain racial disparities in the
actual use of cardiac catheterization, controlling for
the effects of clinical and sociodemographic charac-
teristics.9 We found that although African Americans
were more likely than whites to indicate a strong re-
liance on religion and to report racial and social class
discrimination, and less likely to indicate a general-
ized trust in people, they did not differ from white
patients on numerous other attitudes about health and
health care. More importantly, patient health beliefs
did not explain the observed racial differences in use
of cardiac catheterization, but physician assessments
of patients did explain some of the variation. In par-
ticular, physician ratings of coronary artery disease
and the importance of cardiac catheterization for each
individual patient (both higher for white patients)
contributed to the observed racial disparities in car-
diac catheterization use, beyond what could be at-
999
 Sociodemographic
Factors
factors
influencing the
patient Health-related beliefs
and attitudes

Factors Physician attitudes Patient-physician

relationship
influencing the
physician
Patient clinical Patient
characteristics decision Procedure
Physician performed
recommendation

Health care system

organization of services
System factors
Availability of cardiac
procedure technology

Reimbursement/
financing

Source: Kressin NR, Petersen LA. Racial variations in cardiac procedures: a review of the literature and prescription for future
research. Ann Intern Med 2001;135:352-66.

Figure 1. Overall conceptual model

tributed to clinical differences identified by chart
review. These physician assessments may have cap-
tured the effects of other unmeasured clinical vari-
ables, but our inclusion of numerous relevant clini-
cal indicators that physicians rely on to make
decisions to send patients for cardiac catheterization
minimizes this possibility. Thus, this study, the first
to comprehensively examine the possible contribu-
tion of patient beliefs to observed disparities in care,
found no support for the hypothesis that patients’
preferences contribute to observed disparities. It will
be important for additional studies to examine this
issue further and discern whether the finding is rep-
licated in other clinical situations and settings, in-
cluding dentistry.
An additional factor that may influence dispari-
ties in care is how well the field has communicated
the importance of specific dimensions of health to
the general population and to subgroups of the popu-
lation. For example, within dentistry, do patients and
clinicians sufficiently understand (and understand
equally well across population groups and subgroups)
that dental health influences general health? Have
findings about periodontal disease and preterm birth,
or control of diabetes, or the development of other
systemic health problems, been sufficiently well
communicated to and understood by patients (and
the clinicians who treat them) who are especially at
risk for having physical health problems compounded
by dental disease?
More Research Needed
Because no definitive causal mechanism for
disparities in care has been yet identified, more re-
search is needed that moves beyond access to care
as a possible causal factor. Multidimensional stud-
ies that include patient preferences, physician-, and
system-level factors are needed to explore the full
range of possible etiologies.
Without understanding the true impact and rela-
tive importance of the potential causal factors, ef-
fective interventions to eliminate disparities cannot

1000 Journal of Dental Education ■ Volume 69, Number 9

be designed. Future research should comprehensively
and simultaneously examine the full range of vari-
ables relevant to racial differences in the provision
of health care. On the basis of numerous reviews of
the evidence,1,8,10 it is proposed that future compre-
hensive studies include variables from the patient
(including psychosocial, sociodemographic, and
clinical variables), the clinician (including clinical
assessments and attitudes and beliefs about specific
patients), and the health care system itself (includ-
ing availability of services). Furthermore, because
previous findings show racial differences in use of
preventive care and general use of dental services,
future studies should seek to identify factors that af-
fect treatment decision-making earlier in the diag-
nostic process.11
Although more research on the reasons for ra-
cial differences in care is clearly needed, several
promising avenues may help to reduce racial dispari-
ties. Improving providers’ cultural competence and
communication skills and increasing the number of
racial/ethnic minority clinicians will likely improve
relations between providers and minority patients and
may increase patient satisfaction and improve health
outcomes.12,13 By recognizing racial and ethnic dis-
parity in health care as a quality issue14 and ensuring
that accurate and appropriate data are available to
monitor disparities in care, we will improve our
chances of decreasing disparities, allowing us to
move toward meeting the goals of the Initiative to
Eliminate Racial and Ethnic Disparities in Health.
Current Calls for Action
Already, the federal government, funding agen-
cies, and the community are calling for action to re-
duce health and health care disparities. This is chal-
lenging because the knowledge base regarding the
causes of disparities is not yet sufficient to point to
definitive interventions; however, efforts have al-
ready begun to try to use various interventional strat-
egies to examine their efficacy. Such efforts include
increasing the awareness of researchers, clinicians,
and patients about disparities, increasing the provi-
sion of interpreter services, increasing the diversity
of the health care workforce, increasing the cultural
competency of health care providers and of public
health promotion efforts, and increasing/improving
data collection and evaluation to monitor disparities
as a quality issue and to evaluate intervention effects.
September 2005 ■ Journal of Dental Education
The Kaiser Family Foundation launched one
such initiative, designed to increase physicians’
awareness of disparities in care (www.whythe
difference.org), which included running color adver-
tisements in major medical journals that were de-
signed to pique providers’ interest and draw them to
the website, which then offered greater detail about
the current knowledge of disparities in care.
Summary
In summary, while there is a well-described
picture of the types of health and health care dispari-
ties that exist, particularly in medicine, the causes of
such disparities remain poorly understood and war-
rant much greater attention in the future. Dentistry
will especially benefit in the future from an increased
knowledge base regarding disparities and their
causes.
REFERENCES
1. Smedley B, Stith A, Nelson A, Committee on Understand-
ing and Eliminating Racial and Ethnic Disparities in
Health Care, Board on Health Sciences Policy, eds. Un-
equal treatment: confronting racial and ethnic disparities
in health care. Washington, DC: National Academy Press,
2002.
2. Kiyak HA, Reichmuth M. Barriers to and enablers of older
adults’ use of dental services. J Dent Educ 2005;69(9):
975-86.
3. Dolan T, Atchison K, Huynh T. Access to dental care
among older adults in the United States. J Dent Educ
2005;69(9):961-74.
4. Department of Health and Human Services. Initiative to
eliminate racial and ethnic disparities in health. At:
www.raceandhealth.hhs.gov/. Accessed: October 2004.
5. Oral health in low-income populations. Washington, DC:
U.S. General Accounting Office, 2000.
6. Oral health in America: a report of the surgeon general.
Rockville, MD: U.S. Department of Health and Human
Services, National Institute of Dental and Craniofacial
Research, National Institutes of Health, 2000.
7. Kressin N, Boehmer U, Berlowitz D, Christiansen C, Pit-
man A, Jones J. Racial variations in dental procedures:
the case of root canal therapy vs. tooth extraction. Med
Care 2003;41:1256-61.
8. Kressin NR, Petersen LA. Racial variations in cardiac
procedures: a review of the literature and prescription for
future research. Ann Intern Med 2001;135:352-66.
9. Kressin N, Chang B, Whittle J, et al. Racial disparities in
cardiac catheterization as a function of patient perspec-
tives. Am J Public Health 2004;94:2091-7.
10. Lillie-Blanton M, Rushing O, Ruiz S, Mayberry R, Boone
L. Racial/ethnic differences in cardiac care: the weight of
1001
 the evidence. Washington, DC: Henry J. Kaiser Family
Foundation and American College of Cardiology Foun-
dation, 2002.
11. Gilbert G. Racial and socioeconomic disparities in health
from population-based research to practice-based re-
search: the example of oral health. J Dent Educ
2005;69(9):1003-14.
12. Cooper L, Powe N. Disparities in patient experiences,
health care processes, and outcomes: the role of patient-
provider racial, ethnic, and language concordance. Balti-
1002
more: Johns Hopkins University, The Commonwealth
Fund, 2004.
13. Saha S, Komaromy M, Koepsell T, Bindman A. Patient-
physician racial concordance and the perceived quality
and use of health care. Arch Intern Med 1999;159:997-
1004.
14. Fiscella K, Franks P, Gold M, Clancy C. Inequality in
quality: addressing socioeconomic, racial, and ethnic dis-
parities in health care. JAMA 2000;283:2579-84.
Journal of Dental Education ■ Volume 69, Number 9