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Improving Quality and Eliminating Disparities, Twin Goals for Improvement

By Sarah Klein

There's no shortage of evidence that racial and ethnic minorities in the United States have less access to health care and poorer treatment outcomes than whites. Multiple studies document higher mortality rates for specific diseases and less-than-adequate screening and prevention measures, including mammograms, cholesterol testing, and prenatal care.

The evidence of disparity covers all of the traditional measures of health care quality: clinical performance, patient perception of quality, and outcomes data. Minorities, for example, report more problems communicating with their physicians and having their care expectations met while hospitalized. Yet, many quality improvement initiatives fail to incorporate information about race and ethnicity that would allow institutions to identify problems, make improvements, and measure the impact of changes.

Disparities Unacknowledged
One reason quality improvement programs aren't attending to disparities is that few hospitals, health plans, and providers believe they are delivering disparate health care in the first place. "Many providers are aware of disparities existing on a national level, but believe they exist in other locations," says Thomas D. Sequist, M.D., M.P.H., an instructor of health care policy at Harvard Medical School and a physician at Brigham and Women's Hospital in Boston who has studied the impact of quality-of-care initiatives on different demographic groups.

"There's a general sense that this is not happening in my house," says Romana Hasnain-Wynia, Ph.D., vice president, research, of the Health Research and Educational Trust (HRET). HRET recently trained staff at 10 hospitals to collect consistent information about patients' race, ethnicity, and primary language (as part of the Robert Wood Johnson Foundation's Expecting Success program). By combining this information with quality measures, providers will be able to gauge the extent and nature of disparities and design programs to address them.

For experts in minority health, racial and ethnic equality in health care is inextricably tied to quality. A discussion of quality "is incomplete without that dimension," says Ernest Moy, M.D., M.P.H., lead staff for the Agency for Healthcare Research and Quality's National Healthcare Disparities Report and the National Healthcare Quality Report. "If we say we can improve quality, but only for some, that others will be left out, Americans would say that's [an] unacceptable direction to go," Moy says.

In Moy's experience, the issue of equity tends to interest and motivate the public in a way that the topic of quality does not. "If you talk about quality, people's eyes glaze over. If you talk about disparities, it gets people's attention. They can understand it," Moy says. From there, it's an easy transition back to the less-accessible, but equally important quality issues that ultimately affect all patients.

Gathering Information
To identify problems, medical groups, hospitals, and health plans must institutionalize the collection of racial, ethnic, and language measures. That is harder than it appears, Hasnain-Wynia says. "It seems like it wouldn't be rocket science," she says. "But you are talking about changes in workflow and changes in behavior. You are asking them to reconfigure their information technology systems," she says. "That said, it's doable."

Physicians and other caregivers often are reluctant to ask patients for racial and ethnic information, as they fear offending the patient and disrupting the relationship. In the South, where well-intentioned leaders have worked to make their organizations race-blind, building new race-sensitive procedures may feel like a step backward. There's also concern about the legal consequences of raising the issue of race, which some patients might view as a civil rights violation. The result is that providers end up "eyeballing" patients for racial and ethnic information—a process fraught with error as it is difficult to visually distinguish members of some ethnic groups.

Providers' fears aren't unfounded. When Hartford, Conn.–based insurer Aetna Inc. initially sought permission from federal regulators to collect information about their members' race and ethnicity, the Department of Health and Human Services (HHS) turned the request down, says Floyd Green, Aetna's head of emerging markets. Aetna had to agree not to share the information with its sales and marketing department to obtain federal approval and now only collects information that members disclose voluntarily.

As a result, they've collected data on 4 million members, roughly 26 percent of the company's nationwide enrollment. Still, such a sample is sufficient to draw conclusions about members' needs and design programs to meet them, Green says. Improving reporting by making such disclosures mandatory would be a mistake, he believes. "Certain ethnicities do not trust in the medical community. To make it mandatory might create a certain fear," he says.

Data Can Suggest Solutions
With more information, researchers can move to the next step: determining the causes of disparities and identifying the most effective solutions. "There's a real need for studies that document what type of intervention may be effective," Sequist says. "We know that there are different outcomes for African Americans in the treatment of cardiovascular disease, and we know it is a function of many things including patient preference and clinical decision-making, but we don't know how to fix the differences we see," he says.

Focused quality improvement programs are most needed, Sequist says, in areas where the prevalence of disease is high and "where there appear to be larger-than-average gaps" in treatment outcomes between groups. Diabetes is a prime example. It affects minorities to a greater extent than whites, and there are wide disparities in management of the condition, despite the existence of effective treatments, he says.

Geographic variability in disparities and care quality also may lead communities to prioritize conditions differently. Decisions about where to focus attention should take this local context into account, says Moy. "Community data can hone in both issues. It can help identify those types of care in greatest need of intervention and then suggest if the intervention should be focused on quality, disparities, or both." With local information, communities "could better address structural issues like the lack of specific types of providers or facilities in particular neighborhoods," he says.

Paying providers to reduce disparities may be one way to close the gap. But experts urge caution, as a program's design could determine whether it achieves the desired outcomes. Asking doctors to diminish the disparities in care between whites and minorities, for example, could cause some to exclude minorities from their practice. Or you may find "the top will come down, rather than the bottom coming up," says Meredith Rosenthal, Ph.D., associate professor of health economics and policy at the Harvard School of Public Health.

Using QI to Target Disparities
A better goal would be to encourage improvement in quality overall with interventions customized to the unique needs and perspectives of patient subgroups, taking into account language differences, cultural preferences, and social environments. As a recent study in the New England Journal of Medicine by researchers at RAND Corp. suggests, the quality of health care is poor for all Americans.

And the most effective methods of reducing disparities involve quality initiatives. The two tend to go hand in hand, says Garth N. Graham, M.D., M.P.H., deputy assistant secretary for minority health for the HHS. Part of the reason, he says, is that you're sending the message that "health disparities are a quality of care issue."

Related Articles

L. S. Hicks et al. (2005) Is Hospital Service Associated with Racial and Ethnic Disparities in Experiences with Hospital Care? American Journal of Medicine 118, 529–535.
K. Scott Collins et al. (2002) Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans. The Commonwealth Fund.
Institute of Medicine (2002) Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.
D. Stone (2006) Reframing the Racial Disparities Issue for State Governments. Journal of Health Politics, Policy and Law 31, 127–152.
B. K. Gibbs et al. (2006) Reducing Racial and Ethnic Disparities: Exploring an Outcome-Oriented Agenda for Research and Policy. Journal of Health Politics, Policy and Law 31, 185–218.
T. D. Sequist et al. (2006) Effect of Quality Improvement on Racial Disparities in Diabetes Care. Archives of Internal Medicine 166, 675–681.
A. C. Beal (2004) Policies to Reduce Racial and Ethnic Disparities in Child Health and Health Care. Health Affairs 23, 171–179.
D. W. Baker et al. (2005) Patients' Attitudes Toward Health Care Providers Collecting Information About Their Race and Ethnicity. Journal of General International Medicine 20, 895–900.
S. M. Asch et al. (2006) Who Is at Greatest Risk for Receiving Poor-Quality Health Care? New England Journal of Medicine 354, 1147–1156.

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