By Christopher Guadagnino, Ph.D.

Aline Holmes, RN

Published November 2007 

• React to this article in the Discussion Forum.

While efforts to improve health care quality through evidence-based medical practices have yielded success in many venues, a vexing gap in health status between ethnic/racial minority populations and majority white populations persists, and may be widening. Even when access to health care is factored out as a possible barrier, vulnerable populations – those with major health problems and poor relationships to the health system – continue to experience serious disparities in health outcomes, and experts continue to ponder causes and best intervention courses.

Definitive causes of persistent health disparities remain elusive, but recent research from key agencies sheds new light on the issue, as well as which models of intervention may hold the most promise for closing the health status gap. Principles of those models are being applied at the state and local level in New Jersey.

A surge in health disparity research aimed at leveling the health care playing field for vulnerable populations was galvanized by the 2002 Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, which found a consistent body of research demonstrating significant variation in health care quality by race of patients, even when insurance status, income, age and severity of conditions are comparable. Analyzing sources of disparities at the patient, clinical encounter,

and system levels, the report noted that the conditions under which many clinical encounters take place – characterized by high time pressure, cognitive complexity, and pressures for cost-containment – may result in care that is poorly matched to minority patients’ needs. The report also noted that racial and ethnic disparities in care may emerge, in part, from a number of patient-level attributes, e.g., minority patients are more likely to refuse recommended services (although differences in refusal rates are small), adhere poorly to treatment regimens, and delay seeking care – behaviors and attitudes that can develop as a result of misunderstanding of provider instructions, mistrust, a poor cultural match between minority patients and their providers, poor prior interactions with health care systems, or simply from a lack of knowledge of how to best use health care services.

Among the IOM report’s recommendations were to:

· Increase awareness of racial and ethnic disparities in health care among health care providers and key stakeholders.

· Promote the consistency and equity of care through the use of evidence-based guidelines.

· Enhance patient-provider communication and trust by providing financial incentives for practices that reduce barriers and encourage evidence-based practice.

· Support the use of interpretation services where community need exists.

Compelling evidence indicates that race and ethnicity correlate with persistent, and often increasing, health disparities among U.S. populations. The Department of Health and Human Services (HHS) has selected six focus areas in which racial and ethnic minorities experience serious disparities in health access and outcomes at all life stages:

Infant Mortality. In 2000, the black-to-white ratio in infant mortality was 2.5 (up from 2.4 in 1998), while this widening disparity between black and white infants is a trend that has persisted over the last two decades.

Cancer Screening and Management. African-American women are more than twice as likely to die of cervical cancer than are white women and are more likely to die of breast cancer than are women of any other racial or ethnic group.

Cardiovascular Disease. In 2000, rates of death from diseases of the heart were 29 percent higher among African-American adults than among white adults, and death rates from stroke were 40 percent higher.

Diabetes. In 2000, African-Americans were twice as likely to have diagnosed diabetes compared with Whites, and Hispanics were 1.9 times more likely.

HIV Infection/AIDS. Although African-Americans and Hispanics represented only 26 percent of the U.S. population in 2001, they accounted for 66 percent of adult AIDS cases and 82 percent of pediatric AIDS cases reported in the first half of that year.

Immunizations. In 2001, Hispanics and African-Americans aged 65 and older were less likely than Non-Hispanic whites to report having received influenza and pneumococcal vaccines.

Despite several years of national focus on the issue, the Agency for Healthcare Research and Quality’s 2006 Disparities Report notes that racial and ethnic minorities continue to receive poorer quality of care as compared to whites in 22 essential quality of care measures.

The importance of a national focus on disparities in health status is magnified in light of the demographic changes that are anticipated over the next decade, notes the Centers for Disease Control and Prevention, as groups currently experiencing poorer health status are expected to grow as a proportion of the total U.S. population, and the future health of America as a whole will be influenced substantially by our success in improving the health of these groups.

Over the past few months, a fresh wave of health disparities research has emerged, noting the persistence of disparities and advancing specific models of intervention that are in synch with the IOM’s general recommendations.

In the September/October 2007 issue of Health Affairs – a thematic issue devoted to "refocusing the conversation" on caring for vulnerable populations – the editors note that fiscal reversals and strains on the health care system had dampened hopes of realizing major reductions in health disparities by mid-decade. Federal health disparity reduction initiatives such as Healthy People 2010, released in 2000, had made elimination of specific disparities one of the nation’s highest health priorities and provided baseline data specific to minority populations. But data from the 2006 National Healthcare Disparities Report, and the Midcourse Review of Healthy People 2010 reported no major reductions in most of the racial and ethnic health disparities tracked, with some gaps growing, while health improvements were reported for the overall population.

Researchers writing in the special Health Affairs issue posit a reason for that outcome – investing insufficient local health resources in overall health improvement, thereby undermining programs to help the most burdened minorities catch up – and they recommend collecting highly detailed local disparity data to facilitate locally appropriate resource allocation decisions and help to shape locally-tailored interventions.

Other researchers suggest that there are limits to medicalizing policy responses to health disparities, while the Health Affairs editors note that for years "the center of gravity for public policy initiatives intended to improve the health status of the most vulnerable has remained fixed on improving access to care," while "[f]ar less consideration has been given to equally important ‘upstream’ factors affecting the overall health of the population, including socioeconomic status, education, and the built environment."

That observation establishes a theme that characterizes some of latest research on health disparity, namely, that medical interventions should attempt to incorporate findings about nonmedical determinants of health status, including cultural and community-based factors, recognizing that those "upstream factors" play a decisive role in the health status of vulnerable populations, independent of insurance and access to health care services.

The importance of socioeconomic status, for example, is well-established as being associated with almost every measure of health care, including infant and adult mortality, morbidity, health behavior, impairment and disability; while those who have more income and education are likely to respond more effectively to health-promoting medical opportunities and innovations, write David Mechanic and Jennifer Tanner of the Institute for Health, Health Care Policy, and Aging Research at Rutgers, the State University of New Jersey. Interventions that demand individual initiative – such the tax credits for health-promoting activities, they write, typically favor those with greater personal and social resources even among the poor, and may increase some types of disparities.

"We often neglect the front end, the whole range of pre-pathologies, which doesn’t always fit the political terrain," according to Tom Miller, resident fellow at the American Enterprise Institute. Education that may encourage more health-promoting behavior; behavioral factors such as diet, exercise and tobacco and alcohol control; and social norms collectively account for much more variance in predicting health outcomes and producing disparities than differences in the use of health care itself or the financing of health insurance, according to Miller.

Federally Qualified Health Centers and physicians who are underpaid by Medicaid can still get more "bang for their buck," Miller says, by implementing a "health-capital" approach that encourages vulnerable populations to invest in better health outcomes relative to total resources that have to be consumed. Such a strategy should expand counseling support to encourage more future-oriented behavior, and offer more useful health information and assistance in navigating a complex health system, according to Miller. "A patient who wants better health may not mean more care is provided. It could mean a more sensitive relationship with the physician, and the way that the physician is delivering the care – not just ‘hitting the checklist’ of best practices," Miller adds.

Cultural and social factors also play a part in other new and important research on health disparity. Three generalizations can be made about the most promising intervention strategies to improve quality of health care for minorities and reduce health disparities as an outcome, according to Marshall H. Chin, M.D., MPH, director of Finding Answers: Disparities Research for Change, a national program funded by the Robert Wood Johnson Foundation (RWJF) which undertook a literature review of over 200 racial and ethnic health disparity interventions in the quality improvement literature and published its findings as a Special Supplement to the October 2007 issue of Medical Care Research and Review. Effective strategies will include:

· Multifactorial interventions that address multiple levers of change, i.e., improving multiple components or stages of care for a given condition. For example, increasing breast cancer screening is only useful if patients have timely diagnostic testing after an abnormal mammogram and appropriate treatment for breast cancer; effective depression interventions will address evaluation, treatment, completion of treatment, access to providers, and payment; and effective diabetes interventions will target patient, provider, organization, and community factors simultaneously.

· Culturally tailored quality improvement, i.e., providing a mechanism for individualizing care with case managers and community health workers to help patients understand their care regimen requirements and navigate the health system.

· Nurse-led interventions within the context of wider system change, e.g., disease management programs to track patient care and render follow-up care when needed. Nurse-led followup is often more effective at reducing disparities than interventions involving physicians and the office visit, says Chin, perhaps because nurses are familiar and comfortable working in teams, are traditionally more patient-centered, and by training and background may be more likely to use appropriate culturally tailored approaches.

In addition to cultural and community-based interventions to reduce health disparities, there is evidence that generic quality improvement – particularly that which focuses on systems of care – closes the quality gap, says Anne C. Beal, M.D, MPH, director of the Commonwealth Fund’s Program on Quality of Care for Underserved Populations. To illustrate a systems-improvement focus for disparity reduction, Beal notes that African-American women are much more likely to die from breast cancer than white women, even though the prevalence of the disease in them is lower and mammogram rates are comparable. A study at Mount Sinai School of Medicine in New York City, supported by the Commonwealth Fund, found that minority women with early-stage breast cancer were less likely than whites to receive proven adjuvant therapies. A root cause analysis determined that, while most of the white women were being referred from within the hospital, most black women were being referred from outside hospitals and experienced problems with information handoffs by surgeons after having biopsies performed, says Beal. Results were not getting back to primary care physicians, resulting in missed opportunities to optimize their outcomes with appropriate treatment. The lesson learned, says Beal, was to implement systems to ensure that patient handoffs are done more carefully.

One system of care holds particular promise for reducing or eliminating health disparities, says Beal: the patient-centered medical home, in which patients have a regular provider or place of care, experience no difficulty contacting their provider by phone, experience no difficulty getting care or advice on weekends or evenings, and experience office visits that are always well organized and on schedule. A June 2007 Commonwealth Fund report surveyed minority and low-income patients and found that a medical home eliminated disparities in quality of care between minority and white patients, including access to acute and preventive care, chronic disease management, and coordination between regular providers and specialists, says Beal.

The report also noted that community health centers and public clinics – which care for many uninsured, low-income and minority adults – are less likely than private doctors’ offices to have features of a medical home, and it recommended that improving the quality of health care delivered by those safety net providers can have a significant impact on disparities by promoting equity and ensuring access to high-quality care through the medical home model of care.

The recent health disparities research offers practical guidance to physicians who are committed to reducing health disparities in their patient populations, while the central role of cultural and community-based factors is being incorporated into state and local intervention efforts.

Most physicians are caring, conscientious individuals who believe that disparities in health care quality couldn’t happen in their practice, but health disparities may occur from the way that systems of care delivery are set up, rather than from conscious decision, says John Lumpkin, M.D., senior vice president and director of The Robert Wood Johnson Foundation's Health Care Group. Physicians should set up their practices to incorporate three proven disparity-reduction factors, he says: translators for patients with limited English speaking ability, training in cultural competency, and office practice redesign for quality improvement – e.g., proactively contacting patients who do not come back to discuss results of pap smears, mammograms or diabetes screening tests.

Various CME courses in cultural competency are available – and New Jersey is in the process of identifying those that will soon be required for physician licensure – while practice redesign guidance is available from physician specialty societies and national organizations such as the Institute for Healthcare Improvement, says Lumpkin. While large physician groups are more likely to be able to afford staff for quality improvement activities, and to have electronic health record systems with decision support reminders for patient followup, the ability to identify areas for quality improvement is within reach of small or solo practices without having to hire additional staff, he says. To that end, RWJF is working on a pilot program with the American Board of Medical Specialties to coach small physician practices on methods of office practice redesign, adds Lumpkin.

Physicians can also improve their communication with culturally and linguistically diverse patients by using the National Standards on Culturally and Linguistically Appropriate Services (CLAS) developed by HHS’s Office of Minority Health. The 14 standards are organized by themes: culturally competent care, language access services, and organizational supports for cultural competence.

Boosting the availability of culturally and linguistically sensitive services, and the cultural competence of health care providers is one of several strategies outlined in the Strategic Plan to Eliminate Health Disparities in New Jersey, issued in March by the New Jersey Department of Health & Senior Services (DHSS). Billed as a roadmap to reduce health disparities over the next three years, the plan focuses on certain priority areas of medical emphasis that disproportionately impact minority communities in New Jersey: asthma; breast, cervical, colorectal and prostate cancer; cardiovascular disease; diabetes; HIV disease; infant mortality; unintentional injuries; and obesity, according to New Jersey Health Commissioner Fred M. Jacobs, M.D., JD. Succeeding versions of the plan will focus on other priority health areas including kidney disease, hepatitis C, sexually transmitted infections, immunizations, and violence, he notes. "Reducing and ultimately eliminating these disparities is a core mission of the Department of Health and Senior Services and it has been my top priority since I became commissioner," adds Jacobs.

The plan’s specific goals are to:

· Reduce the number of minorities with asthma who use hospital emergency departments as a main source of care, prevent asthma mortality and make it possible for children and adults to live healthier lives.

· Increase awareness of cancer initiatives and screenings for the New Jersey minority population.

· Reduce the number of deaths due to cardiovascular disease through organized outreach and education efforts.

· Increase the number of minorities living with diabetes who receive high quality care and linkages to social supports.

· Decrease disparities in obesity and increase healthy eating and physical activity across the lifespan among high risk groups (including black and Hispanic populations and those with low socioeconomic status) in New Jersey.

· Reduce the incidence of HIV/AIDS among minority populations through increased education and facilitation of greater access to care.

· Decrease disparities in birth outcomes between white and black infants.

· Reduce excess morbidity and mortality due to unintentional injuries among minorities

· Increase access to language services for those who are more proficient in a language other than English.

· Standardize the collection and reporting of race/ethnicity data across the department.

· Increase minority representation in management/policy-making positions at the department.

· Support new and maintain established partnerships with community-based organizations, including faith-based groups, advocacy groups, and agencies that have minority health agendas to maximize outreach and increase awareness of health disparities.

In addition to boosting the cultural competence of health care providers to achieve these goals, the plan calls for improving standards for collecting and reporting race/ethnicity data, enhancing community outreach, enhancing patient education, and shoring up funding and resources for disparity intervention services.

Jacobs says his department will look to form collaboratives modeled after the Commissioner’s Annual Asthma Summit, which provides a forum to facilitate collaboration among national and local experts on strategies and practices to reduce asthma disparities in New Jersey. The targeted audience includes health care providers, community health workers, health educators, social workers, nurses, and community and faith based organizations. At the conclusion of the first Summit in September 2005, health care providers were challenged to: implement new asthma interventions to reduce the disproportionate impact of asthma in the pediatric and low-income population, and minority communities; incorporate best practices as the basis of asthma management and decision-making; and develop partnerships with public and community health systems to empower citizens to take actions to improve the health of individuals, families and communities. A Diabetes Summit was launched last year, and Jacobs expects to start one soon to address hypertension.

Family and patient education models of disparity reduction hold the most promise, Jacobs believes, and New Jersey hopes to build on the successes of the community coalition model, as illustrated by the statewide Pediatric/Adult Asthma Coalition of New Jersey (PACNJ), comprised of over 150 participating member organizations and six task forces working with schools, physicians, health insurance companies, community groups and environmental agencies to reach all individuals in New Jersey and provide them with the most effective methods for managing their asthma. PACNJ is targeting local settings for its initiatives, including: developing policies and practices for asthma-friendly childcare settings; distributing resources to parents of school-age children, school nurses and pediatricians to create individualized asthma management plans; hosting "train-the-trainer" programs in three urban cities with the highest asthma hospitalization rates; distributing Asthma Friendly School awards; and running annual media campaigns.

There are excellent opportunities to target disparity reduction initiatives efficiently at the hospital level, as about 80 percent of minorities in the U.S. are cared for by 20 percent of the hospitals in the country, according to Lumpkin. A RWJF hospital quality improvement collaborative program – Expecting Success: Excellence in Cardiac Care – selected ten hospitals across the country, each of which serves a high ratio of minority patients, to work collaboratively on improving cardiovascular care for African-Americans and Latinos, develop effective quality improvement strategies, and share relevant lessons with health care providers and policymakers. The hospitals successfully demonstrated improvement in adherence to national clinical guidelines for cardiac care, says Lumpkin.

RWJF is replicating the program in its home state of New Jersey, which has a large minority population, and where studies show that African-Americans have higher death rates than whites for both heart disease and stroke, while preventable hospital rates for heart failure and angina are highest among Latinos. The two-year, $3.5 million initiative – New Jersey Health Initiatives (NJHI): Expecting Success in Cardiac Care – will collaborate with the national program to share and apply best practices to reduce health disparities in cardiac care, while the new cardiac care learning network will be administered by the Quality Institute of Health Research and Educational Trust of the New Jersey Hospital Association (NJHA), which will monitor each hospital’s progress, provide a forum for the ten hospitals to share lessons learned and model best practices, and convene quality improvement sessions with national experts, according to the Aline Holmes, RN, the project’s director and NJHA’s senior vice president of clinical affairs.

The program’s participants are: AtlantiCare Regional Medical Center, Christ Hospital, Cooper University Medical Center, East Orange General Hospital, Newark Beth Israel Medical Center, Palisades Medical Center, St. Joseph’s Regional Medical Center, South Jersey Healthcare Regional Medical Center, Trinitas Hospital, and UMDNJ-University Hospital.

Using CMS core quality measures for heart failure, the ten hospitals are collecting baseline data from their heart failure programs, as well as data on their inpatient population by race, ethnicity, primary language, and highest level of education, says Holmes. By tracking those data monthly, the hospitals can break out data by race and ethnicity and begin to examine possible causes for disparities, such as cultural factors, socioeconomic status, language proficiency, health literacy, and access to primary care, she says. Rapid-cycle improvement methods can then be deployed to test new interventions targeted at reducing disparities and to track their impact on minority patients. The CMS quality measure for discharge planning, for example, includes six or seven things a patient must know, and data analysts can examine the discharge instructions actually given to patients – potentially revealing the need to revise educational encounters or information pamphlets to be culturally sensitive to different populations, notes Holmes.

The NJHA Quality Institute is involved in another initiative at three New Jersey hospitals designed to overcome language and cultural barriers to effective treatment: a pilot project to replicate the "Project Dulce" model of care for diabetes, which was designed by the Whittier Institute for Diabetes/Scripps to address challenges related to successful control of diabetes among underserved populations through a comprehensive, culturally specific disease management program that provides outreach and education, recruitment, screening, diagnosis, clinical care and educational services to low-income individuals, says Holmes.

The project uses clinical teams that include a registered nurse/certified diabetes educator, medical assistant and a registered dietitian who are bilingual and bicultural. Patients meet with their team several times after an initial visit and scheduled follow-up, while reminders are phoned in to patients about upcoming appointments. Patients also participate in an eight-week group self-management training program, led by peer educators who themselves were of the same cultural or ethnic group as the participants. An efficacy study by researchers from the University of California San Diego found that participants in the national Project Dulce showed clinically significant improvements in A1C, blood pressure, low-density lipoprotein and triglycerides.

Project Dulce’s combination of peer education, health promotion and clinical care is designed to measure the effect on clinical outcomes, adherence to American Diabetes Association and American Heart Association standards of care and cultural beliefs in high-risk indigent minorities – primarily low-income, under-insured Latino men and women, notes Holmes.

Financial incentives by health care purchasers and insurers can provide powerful leverage for health disparity reduction, according to January Angeles, program officer for the Center for Health Care Strategies, Inc. (CHCS), a New Jersey-based nonprofit health policy resource center that works with state and federal agencies, managed care organizations, purchasers, providers and community-based organizations to develop programs to improve the quality and cost-effectiveness of health care services for low-income populations and people with chronic illnesses and disabilities.

The Medicaid program in particular can be an important catalyst for addressing disparities in care and outcomes, says Angeles, given that as many as half of Medicaid’s 52 million beneficiaries are members of racial and ethnic minority subgroups, and over 60 percent of them are enrolled in managed care. States can use their regulatory and purchasing influence to engage Medicaid managed care organizations and providers in identifying and actively addressing racial and ethnic disparities in care, incorporating disparity reduction goals and objectives into health plan and provider contracts, and linking monetary incentives to initiatives to reduce disparities in health care (while ensuring that quality of care for white patients doesn’t decrease), Angeles notes. CHCS is working with 12 state Medicaid agencies to improve data collection and use of data on race and ethnicity, and with a group of 12 Medicaid managed care organizations to develop and pilot best practices for addressing disparities, notes Angeles.

Commercial health insurers are also an important player, and CHCS recently received a major contract from the federal Agency for Healthcare Research and Quality (AHRQ) to support ongoing efforts of the National Health Plan Collaborative, a initiative involving ten of the nation’s largest health insurance plans to address disparities in health care service delivery by developing standards for collecting primary data on race and ethnicity, exploring solutions to language access problems, and sharing best practices to reduce disparities. The first phase of the collaborative has focused on diabetes care, notes Angeles.

Physicians in solo or small practices – those who are often left out of quality improvement initiatives – may have the opportunity to join a multi-stakeholder collaborative focused on practice site improvements to reduce racial and ethnic disparities, for which CHCS plans to issue a solicitation early next year, says Angeles. The collaborative will likely focus on interventions such as enhanced access, patient registries, the medical home model, and training in quality improvement, Angeles adds.

CHCS also offers physicians a toolkit, Improving Health Care Quality for Racially and Ethnically Diverse Populations that details the experiences of a collaborative workgroup of ten Medicaid managed care organizations and one state primary care case management program that developed new ways to identify members of racial and ethnic subgroups in their enrolled populations, measured the gaps in their care, and explored ways to reduce disparities and improve overall health care quality. The workgroup implemented strategies to identify and address disparities in three areas – birth outcomes and immunizations, asthma care, and diabetes care – while the toolkit provides an overview of the kinds of problems workgroup members identified, their strategies for addressing barriers to care specific to racial and ethnic minorities, and the results of their efforts, says Angeles.