end-stage renal disease may result from longstanding, poorly controlled diabetes. access to indicated services and effective management of diabetes. …
Chapter 6 Conclusions
Equity in health care is an important national goal, both because it
fulfills our commitment to equality of opportunity for all and because it
can improve the overall health of all Americans Although the United
States spends more on health care per capita than any industrialized
nation, some health indicators remain lower than we would like Multiple
studies conducted over the past two decades have documented that
differences in health care related to race, ethnicity, and socioeconomic
status exist in the United States This report assesses the extent of
these differences from a national perspective and examines the capacity of
current datasets to measure and monitor differences across the country
Key Findings
The NHDR presents seven key findings to policymakers, clinicians, health
system administrators, and community leaders who seek to use this
information to improve health care services for all populations:
1 Inequality in quality exists
2 Disparities come at a personal and societal price
3 Differential access may lead to disparities in quality
4 Opportunities to provide preventive care are frequently missed
5 Knowledge of why
disparities exist is limited
6 Improvement is possible
7 Data limitations hinder targeted improvement efforts
Inequality in quality exists
This report presents the most comprehensive national picture confirms that
there is significant inequality in quality in the United States Although
selected research studies have documented disparities in health care
services, these examinations were often limited to specific populations
with specific conditions By using nationally available data sets, a
national view on health care disparities is provided
This first report clearly demonstrates that racial, ethnic, and
socioeconomic disparities are national problems that affect health care at
all points in the process, at all sites of care, and for all medical
conditions-in fact, disparities in the health care system are pervasive
Our conclusions bring us closer to understanding why, where, and how
disparities occur-essential knowledge for devising and targeting programs
to eliminate these inequities
While disparities in health care potentially affect all Americans and
individuals of any population group, they are not uniformly distributed
across populations We are only beginning to
understand the magnitude of
differential burden of illness in populations with special health care
needs, such as minority children and poor patients with disabling chronic
illnesses Geography can play an important mitigating role in health care
disparities Remote rural populations, for example, are clearly at risk
for having worse access and receiving poorer quality care
Examples from the NHDR:
Minorities are more likely to be diagnosed with late-stage breast cancer
and colorectal cancer compared with whites
Patients of lower socioeconomic position are less likely to receive
recommended diabetic services and more likely to be hospitalized for
diabetes and its complications
When hospitalized for acute myocardial infarction, Hispanics are less
likely to receive optimal care
Many racial and ethnic minorities and persons of lower socioeconomic
position are more likely to die from HIV disease Minorities also
account for a disproportionate share of new AIDS cases
The use of physical restraints in nursing homes is higher among Hispanics
and Asian/Pacific Islanders than among non-Hispanic whites
Blacks and poorer patients have higher rates of
avoidable admissions
Disparities come at a personal and societal price
Health care disparities are costly Poorly managed care or missed
diagnoses result in expensive and avoidable complications As discussed in
Unequal Treatment: to the extent that minority beneficiaries of publicly
funded health programs are less likely to receive high quality care, these
beneficiaries-as well as the taxpayers that support public health care
programs-may face higher future health care costs[?] The personal cost
of disparities can lead to significant morbidity, disability, and lost
productivity at the individual level At the societal level, distal costs
follow from proximal opportunities that were missed to intervene and reduce
burden of illness For example, end-stage renal disease may result from
longstanding, poorly controlled diabetes The highly morbid and highly
costly condition could potentially be avoided with access to indicated
services and effective management of diabetes
Examples from the NHDR:
Without screening, cancers may not be detected until they grow large or
metastasize to distant sites and cause symptoms Such late-stage cancers
are usually associated with more
limited treatment options and poorer
survival Minorities and persons of lower socioeconomic status are less
likely to receive cancer screening services and more likely to have late-
stage cancer when the disease is diagnosed
Persons of lower socioeconomic position who have diabetes are less likely
to receive recommended diabetic services and more likely to be
hospitalized for diabetes and its complications
Many racial and ethnic minorities and persons of lower socioeconomic
position are less likely to receive recommended immunizations for
influenza and pneumococcus Once hospitalized, some ethnic and racial
minorities, as well as lower income patients, suffer worse quality of
care for pneumonia These differential rates of vaccination and
hospitalization present opportunities for provider-based and community-
based interventions to reduce disparities
Differential access may lead to disparities in quality
Access to health care is an important prerequisite to obtaining quality
care Some access barriers, whether perceived or actual, can result in
adverse health outcomes Patients may perceive barriers to delay seeking
needed care, resulting in
presentation of illness at a later, less
treatable stage of illness For example, a usual source of care can serve
as a navigator to the health care system and an advocate to obtain needed
evidence-based preventive and health care services Of the major measures
of access, the lack of health insurance has significant consequences
Avoidable hospitalizations are a good example of the link between access
and disparities in quality of care These hospitalizations may reflect, in
part, the adequacy of primary care When health care needs are not met by
the primary health care system, rates of avoidable admissions may rise In
contrast, perceived problems with specialty referral do not have clear
clinical consequences
Examples from the NHDR:
Many racial and ethnic minorities and individuals of lower socioeconomic
status are less likely to have a usual source of care
Hispanics and people of lower socioeconomic status are more likely to
report unmet health care needs
While most of the population has health insurance, racial and ethnic
minorities are less likely to report health insurance compared with
whites Lower income persons are also less likely to report
insurance
compared with higher income persons
Higher rates of avoidable admissions by blacks and persons of lower
socioeconomic position may be explained, in part, by lower receipt of
routine care by these populations
Opportunities to provide preventive care are frequently missed
Our health care system continues to emphasize care that occurs after an
illness occurs, rather than preventive services that could potentially
prevent the illness or reduce the burden of disease The NHQR documents
that this is a pervasive issue for all Americans; the NHDR illustrates that
there are significant disparities in the use of evidence-based preventive
services for certain populations For example, while smoking remains the
single most preventable cause of mortality, rates of smoking cessation
counseling during hospitalization are only 40 For blacks, this rate of
smoking cessation counseling is only 29 Given the significant impact on
morbidity, mortality, outcomes, and costs of care, efforts to target
preventive services to populations most at risk would be a critical aspect
of an improvement strategy to decrease disparities
Examples from the NHDR:
Blacks and persons of lower
socioeconomic status tend to have higher
rates of death from cancer Although cancer death rates may reflect a
variety of factors not associated with health care such as genetic
disposition, diet, and lifestyle, screening and early treatment of
cancers can lead to reductions in mortality
Many racial and ethnic minorities and persons of lower socioeconomic
position are less likely to receive screening and treatment for cardiac
risk factors The combination of lower screening and effective treatment
of risk factors, such as smoking among the uninsured, lend themselves to
quality improvement initiatives that can potentially reduce heart disease
disparities among populations at risk
Many racial and ethnic minorities and persons of lower socioeconomic
position are less likely to receive childhood immunizations
Many racial and ethnic minorities and individuals of lower socioeconomic
status are less likely to receive recommended immunizations for influenza
and pneumococcal disease
Knowledge of why disparities exist is limited
There are complicated interrelationships between race, ethnicity, and
socioeconomic status that may result in health
care disparities Although
we may have sufficient data about disparities by race and ethnicity, it is
difficult to tease out the individual contributions of race, income, or
education to these differences For example, we found significantly lower
rates of smoking cessation offered to minority patients However, we
cannot determine how much these differences are affected by different
levels of patient income, education, or types of insurance While the
relationships between these factors may seem theoretical, a better
understanding of the underlying factors that result in disparities could
better target improvement efforts aimed at reducing disparities Further
research may help to sort out these issues for future reports
The NHDR cannot tell us what factors are causally related to health care
disparities, although it does identify factors that may be related to
disparities
Examples from the NHDR:
Many racial and ethnic groups, as well as poor and less educated
patients, are more likely to have report poor communication with their
physicians
Many racial and ethnic minorities and poor patients report more problems
with some aspects of the patient-provider
relationships
Asians, Hispanics, and those of lower socioeconomic status have greater
difficulty accessing health care information, including information on
prescription drugs
Improvement is possible
Although this report offers a sobering view of health care disparities,
there are some positive findings which suggest that targeted improvement
efforts could significantly reduce health care disparities The following
notable exceptions demonstrate what is possible to achieve
Examples from the NHDR:
While blacks and poor patients are more likely to present with later
stage cancers with higher death rates, black women have higher screening
rates for cervical cancer and no evidence of later stage cervical cancer
presentation Alhough it is not possible to demonstrate a causal link,
the significant investment in community-based cancer screening and
outreach programs for cervical cancer may be responsible for the lack of
disparity
Quality improvement efforts have resulted in demonstrable reductions in
black-white differences in hemodialysis A targeted intervention within
a quality improvement culture may offer important lessons in disparity
reduction
Black patients are more likely to receive blood pressure monitoring
without any disparity in blood pressure management A greater perceived
risk for significant cardiovascular disease among blacks may result in
appropriately increased screening rates and treatment for risk factors
Directed public education campaigns about cardiac risk factors and the
importance of an actively involved patient may play an important role in
the lower observed rate of cardiac disparities among blacks
When detailed data are available at the most actionable level, such as
population subgroups, the efficiency of quality improvement efforts can be
enhanced For example, the subpopulation data from the California Health
Interview Survey would allow more targeted prevention efforts directed at
Asians over age 50 in need of colorectal cancer screening The information
on language spoken at home provides a far more precise target population-
Asians who do not speak English were 20 less likely to undergo colorectal
cancer screening than their English-speaking Asian counterparts The NHDR
can also serve to identify the best performers, help others learn from
their experiences, and
disseminate the lessons learned to other
communities Community-based participatory research has numerous examples
of communities working to improve quality overall, while reducing health
care disparities for vulnerable populations
Data limitations hinder targeted improvement efforts
Gaps in national data exist National data currently being collected are
useful for examining many racial, ethnic and socioeconomic disparities in
US health care However, large gaps in the data required for a complete
study of disparities were noted For analyses of disparities related to
racial/ethnic groups, data limitations were found to usually related to
sample sizes
Examples from the NHDR:
Data are often adequate to assess the health care of whites, blacks,
Hispanics, and Asians but are rarely adequate for the study of American
Indians or Alaska Natives AI/AN and almost never adequate for the study
of Native Hawaiians or Other Pacific Islanders NHOPI The majority of
smaller racial/ethnic priority populations cannot be assessed, especially
with regard to the care received for specific health conditions
These disparities in data are exacerbated when the general population
is
subdivided to examine disparities among priority populations and become
severe for many studies of children, the elderly, and rural populations
Data limitations for the study of socioeconomic groups usually relate to
the lack of relevant information included in many health care provider
databases
Current Efforts To Improve Data Quality
More data would improve understanding of disparities
Much is still unknown about disparities in US health care As noted
above, because of data limitations, relatively little is known about
disparities among many populations such as AI/ANs and NHOPIs Studies have
just begun to explore disparities among individuals with special health
care needs-such as the disabled, persons receiving chronic care, and
persons at the end of life In addition, possible disparities in the care
provided for many medical conditions have yet to be addressed
As Federal data continue to improve, the ability to study different aspects
of disparity will increase For example, the expansion of questions
related to barriers to health care and delays in care and the addition of
questions related to cultural competency in the Medical Expenditure
Panel
Survey starting in 2002 are expected to greatly improve the ability to
study disparities in these areas The increase in sample size of over 50
between 2000 and 2002 and the addition of oversamples of Asians and of low
income populations in 2002 will also greatly facilitate disparities
research using MEPS
In addition, new Federal data collections will help fill some data gaps
For example, the recently completed National Survey of Children with
Special Health Care Needs will provide a unique opportunity to examine
disparities in health care among this otherwise difficult-to-study
population
Although health care disparities are a national problem, they vary from
place to place; and solutions will likely be developed at the local as well
as the national level Currently, however, relatively little information
is available about disparities in health care in many States and
localities The measurement tools developed for the first NHDR as well as
in future iterations of the report will be made widely available in hopes
that it can help States and localities measure and understand disparities
at the local level
Better methods would improve understanding of disparities
A
variety of methodological issues also limit understanding of disparities
in health care For example, this first NHDR focuses on measures that have
been developed for, and used to study, access and quality of health care in
the general US population However, priority subpopulations-ie, women,
children, the elderly, each racial and ethnic minority, low income persons,
rural populations, and individuals with special health care needs-often
have different health care priorities and different needs for services
Measures that capture the unique needs of specific priority populations are
required for a fuller understanding of disparities faced by each group
In this first NHDR, income and education level were used in this study as
primary measures of socioeconomic position It is unknown if other
dimensions of socioeconomic position might be more relevant to disparities
in health care, especially in terms of access and quality of services Are
different dimensions relevant for different aspects of health care? If so,
can they be measured? And should they be measured individually or as a
composite measure?
Data and measurement issues also limit the examination of disparities in
health
care as they relate to the urban-rural continuum Most Federal data
collections are able to distinguish MSA from non-MSA counties, and these
two categories form the basis for the geographic analyses presented in this
report However, it is well known that these two categories do not capture
well the heterogeneity that exists along the urban-rural continuum As a
result, disparities being experienced by residents of inner cities and very
rural areas could not be adequately addressed
It is hoped that future NHDRs will benefit from continuing methodological
innovation in each of these areas Such innovations will help to focus
investigation of the most pressing disparities issues and allow a better
understanding of disparities with reduced data collection needs
Knowledge of why disparities exist and how they can be eliminated is
limited
Perhaps the most important limitation of this first NHDR is the scarcity of
information about why disparities in health care exist Causes of
disparities are likely to be multifactorial, complex, and specific to each
priority population and type of health care While DHHS continues to
support research aimed at identifying the root causes of
disparities, much
remains to be known Optimal interventions to eliminate disparities cannot
be developed without knowledge of the causal factors
How such interventions should relate to quality improvement activities is
also relatively unstudied With some notable exceptions such as the HRSA
Health Disparity Collaboratives, interventions to reduce disparities and to
improve quality are often conducted separately Additional research is
needed to understand how efforts to reduce disparities and improve quality
can best be coordinated
Future NHDRs
This report, the first NHDR, could not address all the issues important to
the elimination of health care disparities Future reports will build upon
this initial effort and will seek to fill in gaps as they are identified
Progress will be tracked
The first NHDR is cross-sectional and provides a snapshot of disparities in
the United States at a point in time While some longitudinal data were
gathered, these generally were insufficient to examine trends over time
Future NHDRs will build upon this baseline to identify trends and mark the
progress of the Nation towards the elimination of health care disparities
In addition, future
NHDRs will seek to communicate innovations in
measuring, understanding, and intervening to eliminate disparities as these
are developed
Measures of disparity will be refined
The first set of NHDR measurement tools has limitations The measure set
on the first NHDR is long, and similar concepts are sometimes duplicated by
different data sources In addition, it is generally restricted to common
measures that were developed to assess access to care and quality of care
in the general population Many health care needs and services specific to
particular populations are not addressed
Future NHDRs will build upon the first NHDR measurement tools Data
assembled for the first NHDR, which encompass a broad range of measures,
will enable an informed review of these measures It is anticipated that
the number of measures that are useful for tracking disparities in the
general population will be reduced significantly In addition, measures
specific to particular priority populations will be developed and
incorporated into the measure set
Methods for assessing disparities will be improved
Identified methodological limitations for studying disparities include
problems measuring
socioeconomic position and rurality Future NHDRs will
incorporate refined measures of socioeconomic position and rurality as
these are developed
Knowledge of why disparities exist and how they can be eliminated will be
emphasized
Using this report as a baseline, future NHDRs will be able to report on
best practices and innovations for reducing disparities in health care In
addition, effective ways of coordinating efforts to eliminate disparity and
to improve quality will be presented The continuing simultaneous release
of the NHDR and the NHQR should serve to reinforce the important linkages
between disparities and quality and facilitate the study of solutions that
effectively address both issues
The journey to high quality and equitable health care will be long and
challenging It will be marked by small but continuous improvements At
its end lies the promise of better health and well being for all Americans
The first NHDR and the first NHQR are small but significant steps on this
journey Future reports will mark the progress of the Nation towards a
better health care system for all
Reference
1 Institute of Medicine, Board of Health Sciences Policy, Committee
on
Understanding and Eliminating Racial and Ethnic Disparities in Health Care
Unequal treatment: Confronting racial and ethnic disparities in Health
Care Washington DC: Institute of Medicine; 2003
