The Inequality in Health Care Quality

Achieving the nation’s health care objectives as detailed in Healthy People 2010 is a daunting task, and the deadline is quickly approaching. While the first goal of Healthy People 2010, increasing the quality and years of healthy life, is a formidable challenge, the second goal of eliminating health disparities among minority populations is equally difficult to achieve. Reaching this target requires profound interventions at the health care provider and health care system levels, as well as at the socioeconomic and community levels. To track prevailing disparities in health care delivery, the Healthcare Research and Quality Act of 1999 directed the Agency for Healthcare Research and Quality to develop an annual National Healthcare Disparities Report (NHDR). The 2007 NHDR presents some appalling findings. Consider the following: blacks have a rate of new AIDS cases that is 10 times higher than whites’; American Indians and Alaskan natives are twice as likely to lack prenatal care in the first trimester as whites; Asian adults aged 65 years and older are 50% more likely to lack immunization against pneumonia than white adults; and Hispanics with diabetes are 3 times as likely to have a hospital admission for a lower extremity amputation than whites. Progress has been made in some areas, such as reducing the disparity between black and white hemodialysis patients with adequate dialysis and reducing the disparity between Asians and whites who have a usual care provider. However, the overall disparities are not decreasing by any means, and the largest gaps in health care quality and access have yet to be reduced. Why has our nation not made much progress with regard to disparities in health care? Several reasons have emerged. The 2007 NHDR concluded that lack of insurance is a major barrier to the reduction of disparities; in 6 of 7 measures indicative of poor-quality health care, the most important risk factor was being uninsured. However, the report emphasizes that interactions of many other factors result in disparities. In their position paper on racial and ethnic disparities in health care, the American College of Physicians (ACP) states that “even after adjustment for insurance status and income, racial and ethnic minorities tend to have less access to health care and lower-quality health care than nonminorities. ” In Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the Institute of Medicine (IOM) reports that possible reasons for health care disparities may stem from systemrelated issues, as well as clinical encounters, and/ or patient characteristics. The way in which health care systems are organized affects the health care of minorities. For example, language barriers can pose great hurdles to communication between patients and providers in hospitals and health systems that lack proper translation services. In addition, financial and bureaucratic pressures may not allow many providers to spend the necessary time on a clinical encounter if extra attention is needed due to language or cultural barriers. Finally, due to economic reasons, minorities may be enrolled in lower tiered plans that provide less comprehensive coverage, leading to fragmentation of care for this patient population. The context of the clinical encounter may have a role as well. Although some uncertainty regarding diagnosis, patient response, and/or prognosis is inherent in any clinical encounter, the consequences of this uncertainty are even greater in the case of minority populations. Providers faced with patients from different ethnic or racial backgrounds may be more prone to biases that might AUTHORS’ NOTE: Drs Abouzaid and Maio are from the Jefferson School of Population Health, Philadelphia, Pennsylvania. Address correspondence to Dr Maio at vittorio.maio@jefferson.edu.