Health Disparities are Quality Disparities

The 2008 National Healthcare Quality Report and the National Healthcare Disparities Report from the Agency for Health Research and Quality were and are generally published each year at the same time.

This is very much appropriate, but it is hard to know if people are making the connection between the two reports. If we have health and/or healthcare disparities, particularly in the sense that with most things equal (SES, access, etc.) there are still disparate outcomes or disparities, what does that speak to?

Well, there are few things that we can consider.

1) Genetics: While the data on genetic predisposition is emerging there are pros and cons to this variable. A 2005 editorial The Role of Race and Genetics in Health Disparities Research out of the American Journal of Public Health summarizes the potential role of the human genome mapping in our evaluating causes and approaches to health disparities quite succinctly.

My experience is that given the long history of disparate outcome by race coupled with the emerging understanding of disparities in the LGBT, Disabilities, and other communities, genetics may play a role but the role that they play will be at best complementary.

2) Social, Environmental, Behavioral Factors: Health behaviors differ from person to person. Some of these behaviors are influenced by cultural health models and beliefs, experiences and responses to the health system and healthcare providers, and environmental circumstances. Behavior has and will always have an influence on health outcomes and behaviors will always be influenced by the behaviors of healthcare providers. So, the dynamic is a two-way street. There is evidence that experiences of healthcare providers (of all ethnic backgrounds) influence how treatments and recommendations for treatment are allocated. One classic study of this is a New England Journal of Medicine Article by Schumann, et. al.: The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization.

While there were subsequent articles that questioned the authors' findings and the subsequent media attention that was generated, there was no denying the unequal treatment recommendations were prevalent and conclusive from the data collected in the study. This leads me to one last consideration (for now):

3) Quality Disparities: What do I mean by "quality disparities"? Let's move outside of healthcare for a minute and consider other industries where quality is vital (assume all industries believe it is).

For example, as the president of a company you have been delivering a high-quality product or service for quite sometime. Based on your evaluation and the responses of the customers, you are receiving feedback that what you are producing is consistently good amongst a majority of your customers. You are committed to quality because of your dedication to maintaining integrity but also due to the fact that your competition is fierce and while you are leading the pack, you never take your success for granted.

One day, it is brought to your attention that over 25% of your customers (by industry vertical, geography, or some other variable) are experiencing negative outcomes in the utilization of your product or service, yielding on average 2 times more problems than the other 75%.

What is your response? What do you think?

Well, one response is to say, "we have been delivering quality for so long, what is it with these 25%? We give everyone the same service consistently."

Another response is to say, "where is the breakdown?" Followed by, "is there something that we don't really understand about our customers that will help us serve them better?"

In an environment of stiff competition, you will do your research to understand who these 25% are, what exactly their challenges are and develop solutions to narrow the outcomes gap.

Or, you will decide that these 25% of customers are the problem and let them go, concluding that the 80/20 rule says that they are not necessarily benefiting you that much anyway. This may work or it may take you out of the #1 spot as the industry leader, especially if those segments are fast growing.

Back to healthcare. If 20% or more of our patients are experiencing worse health outcomes than the other 80%, obviously there are disparities there. More than likely, this is also what I would consider a quality issue even if we know that "we are treating everyone the same".

Why is this a quality issue? In fact, why are health disparities quality disparities? The answer lies not in the fact that hospitals are not delivering quality services. I believe that most facilities and individual practitioners are delivering very high quality services. I also think there are distinctions in what translates as quality.

Patient-centered care asks us to treat patients as individuals. It suggests that each patient is functioning and managing their health under a unique set of circumstances and if those circumstances are not understood to as great of an extent as possible, we may miss the mark on their needs short and long term and thus contribute to less than the best outcomes.

Missing the mark is reflective of the quality of services delivered for each person based on their unique needs that can sometimes be a result of archetypal dynamics of a particular group identity.

If over time, certain demographic segments are experiencing poor outcomes (just like a certain vertical or segment of a non-healthcare company) quality is being compromised. Your integrity is not compromised--you are doing all that you know how to do--but your outcomes are unequal and therefore certain groups are not getting what you intend for them to get and in some cases what you promise them based on previous experiences.

The response in healthcare has to be the first response described above for the hypothetical company--understand this population and develop solutions to address their problems. The second option of letting these customers go is not an option in healthcare. While there have been instances in which populations with greatest needs have been met with barriers to treatment because of the challenges they present, this is a response that given the times we are in and the realities of demography, we simply will not and cannot consider. We cannot do it morally nor can we shoulder it economically.

Aligning cultural competence with quality, affordable and accessible care is what the DHW Cultural Competence-Quality Framework for Healthcare Excellence is all about. Understanding that integrated efforts towards eliminating health and healthcare disparities (a core part of our CC-Q Framework) are a critical and central tenant in the quality care that all Americans desire is vital to assuring our success in reforming the healthcare system.

This post is a very short exploration of health disparities being considered as quality disparities. I would like to explore the idea of health disparities compromising our goal of quality affordable care in more detail. Please share your thoughts with me, the Diversity HealthWorks community and all those visiting our blogs.

Make it a great day!