Disparities Dialogue

Moving Beyond Documenting Health Care Disparities

As a physician, a teacher and a passionate advocate of the urgent need to reduce racial and ethnic disparities in health care for the past 20 years, I've grown weary of reports that simply list racial and ethnic disparities without offering proposed solutions. While the 2005 National Healthcare Disparities Report issued from the Agency for Healthcare Research and Quality tracks progress toward eliminating disparities in health care, it leaves us wondering about the implementation of actual change in this area.

The Robert Wood Johnson Foundation (RWJF) has boldly taken the next step. With the launch of the Expecting Success: Excellence in Cardiac Care program, RWJF is working with 10 hospitals and health systems across the country to meld quality improvement with the drive to eliminate health care disparities.

The Quality of Care

The 'inverse care law' suggests that those with the greatest health care needs often have the least resources to address those needs. For example, we know that African Americans and Hispanics are much more likely than their white counterparts to live in poverty, have multiple chronic illnesses, suffer from more severe diseases and therefore require more, not less, medical care.

The problem is that all of these factors also predict reduced access. It might be difficult, for example, for these patients to find physicians who are willing to accept a particular payment option – or they may struggle with age-old roadblocks that restrict access, such as health illiteracy, skepticism toward medical institutions, beliefs about the benefits of medication, and more. Other factors that contribute to disparities in health care for vulnerable populations include low socioeconomic status, inadequate insurance and living in underserved areas, such as inner cities or rural settings.

Despite these conditions, it's clear that if we really want to begin eliminating disparities, the quality of care must be improved for everyone. Efforts must be made toward ensuring culturally competent care, and we also need to devise systems that address each population according to their own specific needs. Until we do that, the inverse care law will be the order of the day.

Expecting Success

I believe that the Expecting Success program can bring needed change. The explicit purpose of the program is to raise the quality of health care for everyone and narrow the gaps between certain racial and ethnic groups. I have little doubt that at the end of the program, care will have demonstrably improved. The 10 participating hospitals have an organizational commitment to help diminish or eliminate disparities, and are focused on moving from analyzing the problem to applying actual interventions. The expertise that the 10 hospitals' teams will gain in improving care for vulnerable populations will better serve all patients. And if the hospitals tackle disparities in cardiovascular care successfully, it will be easier to apply lessons learned to other areas, like cancer.

So the time has come to develop well-designed, targeted interventions to show that quality can be improved and disparities can be diminished, if not eliminated. If we use quality improvement knowledge to show that eliminating racial disparities in health care is possible, hospitals will build the confidence and competence to tackle what was seen as insurmountable just a few years ago. By illustrating success across these 10 hospitals that vary in size, teaching status, demographics and location, other hospitals and health systems across the country will be compelled to act.

A strength of the Expecting Success initiative is that it's a learning collaborative, and the most valuable lessons will come from the hospitals learning from each other. One hospital may lack the money to implement electronic health records (EHRs) for its patients, while another can share how it established a better system for tracking patients' follow-up care without EHRs. I think many aspects of the program will be initiated in the absence of expensive technology, such as implementing standardized patient discharge forms or initiating the concurrent review process before patients have been discharged, instead of waiting until they have left the facility to discover an error. The most important factor is the hospitals' commitment to the program goals, and I think the hospitals will benefit greatly by sharing their knowledge with one another.

Lessons to Be Learned

Prior to their selection, the Expecting Success hospitals demonstrated a commitment to quality improvement and moving forward on the issue of disparities. But there is still a lot to learn. I think one of the toughest lessons is that disparities do exist within hospitals. Even in 2006, hospital staff may think, "Disparities are out there, but they do not exist in my hospital." The assumption is that all patients are treated alike and disparities are driven by other factors such as lack of insurance, but are in no way connected to their patients' races and ethnicities. The first step is for each hospital to begin to look within their facilities – this in itself will be an eye-opening experience.

The hospitals must also ask themselves why disparities exist within their hospital. What are the factors that are relevant in their populations? Every site will be different. In Rochester, NY, the rate of uninsurance is eight percent, but other communities may have a rate of 30 to 40 percent. In those instances, lack of insurance may be the driving factor behind health care disparities. It is a factor in Rochester, but it may not be the driving factor behind disparities.

It's important to learn what really matters within one's own facility, and to then undergo a process of learning from other hospitals and determining what tactics work best. For example, is the issue one of better language translation at the point of care, or is it finding ways to ensure that when patients are discharged they truly understand their condition and exactly how to implement their treatment plan? It's one thing to sign a form that a patient must quit smoking, but it's quite another issue to provide smoking cessation counseling in an evidence-based and culturally sensitive manner. I think getting to that point takes time, experience and a willingness to learn from other institutions.

Potential of the Program

The Expecting Success program could catalyze tremendous interest on the part of hospitals and health systems across the country. The hope is that other organizations will not accept disparities in care among their patient populations, will incorporate this thinking into their mission, and will commit the necessary resources toward eliminating disparities.

Success breeds success. If one hospital demonstrates success, then it could tip the balance so that adoption takes off elsewhere. Unfortunately, in our nation we run the risk of health care disparities and the interventions designed to eliminate them as being seen as a passing trend. Our national attention span is so short; we move from one topic to another so quickly. That's why, in terms of Expecting Success, sharing among the 10 participating hospitals will be a critical factor, and communicating their achievements to hospitals around the country will be even more critical to sustaining a long-term impact. We will all be well-served to follow Expecting Success closely.

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Kevin Fiscella, M.D., M.P.H., is associate professor of Family Medicine and Community & Preventive Medicine at the University of Rochester School of Medicine, and associate director of the Rochester Center to Improve Communication in Health Care. He served as a member of the National Advisory Committee that selected the 10 Expecting Success hospitals, and is currently directing projects sponsored by AHRQ, NICHD, NCI, and RWJF related to racial/ethnic disparities in health and health care.

 

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