Health care disparities continue among minorities, the poor, says HHS
Reports are first national effort to measure quality of U.S. health care
African-American and low-income U.S. residents are more likely to die from cancer, less likely to be insured, and less likely to have usual sources of health care than white and higher-income Americans, recent reports from the U.S. Department of Health and Human Services indicate.
According to the first National Healthcare Disparities Report,1 issued in December 2003 by the Agency for Healthcare Research and Quality (AHRQ), Americans generally receive exceptional quality in health care, but some socioeconomic, racial, ethnic, and geographic differences exist.
Among the report’s key findings:
- Most Americans have access to public or private health insurance, but poor people and some minorities are less likely to be insured. Those same populations, if insured, are more likely to have public insurance.
- People of lower socioeconomic status (SES) and blacks have higher death rates for all cancers combined.
- Hispanics and American Indians or Alaska natives are less likely to have their cholesterol checked.
- People of lower SES and some minorities are less likely to have a usual source of care.
- Rates of admissions for conditions that usually are treatable with ambulatory care are generally higher for people who live in low-income areas compared with those who live in high-income areas.
On the other hand, some of the data on the studied "priority" populations indicate they have better outcomes in some areas than the general population:
- Asians and Pacific Islanders, American Indians/Alaskan natives, and Hispanics have a lower death rate from all cancers.
- Blacks have higher rates of Pap smears and blood pressure monitoring and lower rates of postoperative hip fractures compared to whites.
- Black and Hispanic patients are more likely to report that their health care provider usually asks about medications prescribed by other doctors.
- Hispanics, Asians, and Pacific Islanders have lower rates of hospitalization from influenza.
"The data in these reports provide an important message for the nation — we are making progress in enhancing health care quality and access, but we can do more and we need to do more," says Carolyn M. Clancy, AHRQ’s director. "The first editions of these reports, and those that follow, are an important key to meeting that challenge."
The report, and its companion, the AHRQ’s National Healthcare Quality Report,1 were mandated by the federal Healthcare Quality and Research Act of 1999 (now section 903(a)(6) of the Public Health Service Act). The law requires AHRQ to develop two annual reports: a National Healthcare Quality Report and a National Healthcare Disparities Report.
The quality report evaluates the quality of the health care available to and accessed by Americans overall. The disparities report is designed to track "prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations."
The framework for evaluating both the quality of health care overall, and for disparities in health care, was developed with input from the Institute of Medicine (IOM), the reports’ authors note.
According to the disparity report’s executive summary, both reports were released simultaneously because both should be taken together as an indication of the overall level of quality in health care in the United States.
The disparities report evaluates the quality of health care experienced by "priority populations" compared to the U.S. population overall. The report’s defined priority populations include:
- the elderly;
- racial and ethnic minority groups;
- low-income groups;
- residents of rural areas;
- individuals with special health care needs, specifically children with special needs, the disabled, people in need of long-term care, and people requiring end-of-life care.
Then, the report examines the following aspects of the care received by the priority populations:
- effectiveness — care based on scientific knowledge; is it provided to all patients who could benefit and not provided to patients unlikely to benefit;
- safety — care that avoids injuring patients through care intended to benefit them;
- timeliness — care that reduces delays in use of care;
- patient centeredness — care that is respectful and responsive to the individual needs, preferences, and values of patients;
- equity — care that encompasses the need for health care systems to provide care that does not vary in quality because of personal characteristics (such as gender, ethnicity, geographic location, and SES).
Both reports are supposed to serve as an annual comprehensive snapshot of the performance of our health care system, its strengths, and areas that should serve as a focal point for future improvement, the authors note. The performance measures underlying the two reports will be used to monitor the nation’s progress toward improved health care delivery.
A key challenge in developing the report, however, was defining what constituted a "disparity" in care with the population as a whole. Recent federal reports have come up with a number of different ways of looking at disparities in care. For example, in pursuit of its overarching goal of eliminating health disparities, Healthy People 20102 considers all differences in its measures as evidence of disparities.
At the other end of the spectrum, a recent report by the IOM, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,3 defined health care disparities as differences that remain after taking into account patient needs and preferences and the availability of health care; notably, after an exhaustive literature review, the IOM report concluded that no study ever conducted has met this most rigorous definition of disparities. Still others associate health care disparities with adverse health outcomes, personal responsibility, or provider prejudice.
In the absence of consensus on the definition of disparities, the authors note, AHRQ report will focus on presenting stand-alone facts. Where researchers find variation among populations, this variation simply will be described as a "difference," the report states. By allowing the data to speak for themselves, it continues, there is no implication that these differences result in adverse health outcomes or imply prejudice in any way.
Some health quality advocates, however, are not pleased with the overall focus of the reports and on the broadened focus on variations among populations without examining possible causes.
"Recognizing that the health care disparities identified in the Institute of Medicine’s landmark report, Unequal Treatment, still very much exist, we are perplexed that these two reports appear to shift the focus away from eliminating healthcare disparities," says Roland W. Maxey, MD, PhD, president of the National Medical Association (NMA) in Washington, DC, a professional society for physicians of African descent. "The new focus has as its premise, [the need to] increase health care quality for all’ with emphasis on eliminating health disparities based on race or ethnicity all but disappearing."
Although the new focus may be well intentioned, Maxey says, it is not the most appropriate course to follow when so many Americans, because of their race or ethnicity, do not receive the same level of health care as the majority population.
The IOM report was very clear that some disparities in access to care and in health outcomes could only be attributable to racial or ethnic biases, Maxey tells Medical Ethics Advisor.
By emphasizing a goal of "quality for all," the AHRQ report ignores the fact that not all Americans are starting from the same place, he adds.
"Some populations, historically, have not had access to care, have not had good experiences with health care, some do not even know how to get health information or apply it to their lives," he explains. "Not everyone is going to be able to pull themselves up by their bootstraps. So, just providing that opportunity is not enough."
The reports’ focus, he fears, indicates that funding specifically dedicated to outreach in at-risk populations may be in danger, and the NMA will work to ensure that does not happen.
"We at the NMA, however, commend the effort [at examining the existence of disparities] and we look forward to working with all of those of good will in redirecting how the report is used to create a blueprint for eliminating health care disparities and addressing the IOM’s findings," he said.
Both of the AHRQ’s reports are available for download on-line at: www.qualitytools.ahrq.gov.
1. Dept. of Health and Human Services. Agency for Healthcare Quality Research. National Healthcare Quality Report, 2003. National Healthcare Disparities Report, 2003. Accessed on-line www.qualitytools.ahrq.gov.
2. U.S. Department of Health and Human Services. Healthy People 2010 (2nd ed.), 2 vols. Washington, DC: U.S. Govt. Print. Office; November 2000.
3. Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley D, Stith AY, Nelson AR, eds. Washington, DC: National Academies Press; 2003.
- Carolyn Clancy, Director, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850
- Roland W. Maxey, MD, PhD, President, National Medical Association, 1012 10th St. N.W., Washington, DC 20001, Executive Offices. Phone: (202) 347-1895; fax: (202) 898-2510.