Reducing Health Disparities or Improving Minority

Authors: Melissa R Partin Diana J Burgess

Publish Date: 2012/05/17

Volume: 27, Issue: 8, Pages: 887-889

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Abstract

Improving health outcomes for racial and ethnic minorities in the United States has been a national priority since the Institute of Medicine identified equity as one of the six areas of priority focus for improving health care quality in the United States1 Finding Answers Disparities Research for Change is a national program funded by the Robert Wood Johnson Foundation that seeks to facilitate efforts to improve health care equity in part by conducting and disseminating systematic reviews of the literature on effective strategies for reducing disparities2 This issue of JGIM features five systematic reviews conducted by the Findings Answers program which summarize the published literature on interventions aimed at reducing disparities in asthma human immunodeficiency virus HIV colorectal cancer prostate cancer and cervical cancer Reading these reviews one is heartened by the progress that has been made in the decade since the Institute of Medicine report was released Yet it is striking that while the Finding Answers initiative is explicitly aimed at reducing racial and ethnic disparities in care only a few of the 178 intervention studies included in the five systematic reviews published in this issue actually examined reduction in disparities as an outcome measure The vast majority of interventions focused on improvement in processes or outcomes of care for members of minority groups rather than reductions in disparities a point noted by the authors of the systematic reviews and consistent with the findings of other systematic reviews of disparities interventions3 The distinction between the goals of “reducing health disparities” and “improving minority health” is rarely explicitly addressed in published studies but has important implications for healthcare organizations as they choose and implement interventions as we describe belowThere are certain cases where an organization’s focus should clearly be on reducing disparities The most obvious example is when language barriers have been identified as a contributing factor in poor health care processes and/or outcomes for nonEnglish speaking populations An effective intervention that targets those barriers should have the intended effects of improving care for nonEnglish speakers without affecting Englishspeaking patients thereby reducing the disparity An explicit focus on reducing disparities is also warranted when observed health disparities can be attributed to provider or system factors such as processofcare measures eg testing of HbA1c and LDL cholesterol level or treatment decisions eg decision to prescribe antiretroviral therapy for HIV In such cases systemlevel interventions aimed at providing uniform guidelineconcordant care have been shown to reduce disparities4 – 6The appropriate focus is less obvious when the disparity can be attributed in part to patient behaviors eg control of HbA1c and LDL cholesterol level adherence to antiretroviral therapy and when social determinants of health associated with patient race/ethnicity eg income education health literacy neighborhood in addition to healthcare factors contribute to the disparity by affecting those patient behaviors In those cases intervening on aspects of the healthcare organization such as improving patientcentered care could conceivably improve patientlevel outcomes for both disadvantaged and advantaged groups improving minority health but not reducing the disparity Indeed an analysis of racial disparities observed in the Veterans Health Administration between 2000 and 2009 when the organization underwent a transformation that improved quality of care found a reduction in disparities for processofcare measures but no reduction in disparities in outcomes such as blood pressure glucose and cholesterol control4Should an outcome of improved minority health but stable or worsening disparities following the implementation of an intervention be considered a failure From an organizational perspective the answer to this question may depend in part on the broader context that led to the decision to implement the intervention as well as whether factors contributing to the disparities found are within the organization’s control to modify Our objective here is not to advocate for a stance on the answer to this question but rather to impress upon health care organizations that it is an important question to ask before implementing interventions and program improvements because some intervention strategies might be better suited to reducing disparities whereas others might be better suited to improving minority health To illustrate our point we describe some common intervention strategies below and explain how both the context of observed disparities ie the factors contributing to them and the relative priority assigned to the distinct but related goals of “reducing health disparities” and “improving minority health” can and should influence the choice of intervention strategyOne common intervention strategy that might be wellsuited to the goal of reducing disparities involves targeting an effective program to minorities As mentioned above interventions to address language barriers are a classic example of such a targeted disparity reduction strategy Another example of a targeted disparity reduction strategy would be to offer an effective intervention to those patients with the greatest room for improvement If minorities are disproportionately represented among those with the worst outcomes before the intervention begins and the intervention is equally or more effective among minorities relative to others the program should reduce disparities However a targeted approach may not be appropriate for all circumstances For instance it may not be feasible or acceptable to restrict exposure to interventions designed to modify processes at levels other than the patient to minority groups exclusively Although it is possible to target organizational and provider directed interventions to healthcare facilities or systems with a large minority population it is likely that such interventions would also confer benefits to white patients in those facilities particularly those from vulnerable patient groupsAn alternative strategy for reducing disparities might involve tailoring intervention content to enhance engagement and appeal for a particular cultural group or to address barriers specific to this group under the assumption that such tailoring would increase the effectiveness of the intervention for this group thereby potentially reducing disparities This approach could be an effective approach to reducing disparities if the primary source of variation resides at the patient level and there is evidence of unique barriers in different racial and ethnic subgroups However it may have little impact on disparities if community system or provider level factors dominateStrategies that improve care quality are likely to benefit minorities but may not necessarily reduce disparities Such strategies include implementing standardized interventions designed to reduce variation in how care is provided or redesigning care in patientcentered ways in order to better adapt care processes to individualized patient needs7 One study of medical students which found a positive association between patientcentered attitudes and clinical performance scores among African American standardized patients but not white standardized patients concluded that “patientcentered attitudes may be more important in improving physician behaviors with African American patients than with white patients and may therefore play a role in reducing disparities”8 However organizations should be aware that a possible result of implementing standardized and individualized strategies is improved outcomes for minorities but either no impact on or widening disparities Indeed one health insurance plan found after implementing a standardized diabetes intervention that both African American and white patients showed improvement in glycemic control but that racial disparities apparent at baseline remained unchanged a year after the program was implemented9How to prioritize candidate intervention strategies might also depend on the relative priority placed on two potentially competing perspectives From a utilitarian perspective an intervention that benefits white and nonwhite patients would be preferable to an intervention that benefits only a single group From a moral perspective however the concern for equity and social justice would favor an intervention that reduced racial disparities even if it conferred a lesser net benefit to all patients Given the shameful history of racial injustice in the United States there is a strong moral imperative to reduce racial inequality in health and healthcare which motivates many of us in this area to do the research we do This moral imperative to reduce racial inequality perhaps underlies the decision to frame this research agenda in terms of “reducing health disparities” rather than “improving minority health” despite the fact that the latter might encompass a broader range of outcomes that our interventions and quality improvement initiatives are designed to addressThe systematic reviews in this special symposium point to both the progress made toward healthcare equity marked by a spate of interventions that have been effective at improving health outcomes for minority patients as well as to the gaps that remain in the literature We agree with Chin and colleagues that the time for action is now and that resources need to be targeted toward helping healthcare organizations develop and successfully implement interventions to improve minority health outcomes A difficult question but one that we believe is important to address is whether and under what circumstances healthcare organizations should focus on “reducing health disparities” versus “improving minority health” particularly when there is pressure for organizations to improve the quality of care for all patients Because the best intervention strategy will often vary by these foci we urge healthcare organizations to explicitly address this question as they consider new improvement efforts

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