Healthcare Disparities

Closing the gap

Mildred M G Olivier, Medical Director Midwest Glaucoma Center USA.

Eliminating healthcare disparities is the need of hour. The author discusses various options-increasing self-awareness among physicians, increasing minority representation in the workforce and collecting data and evidence based medicine to increase the quality-of-care for all individuals.

The Institute of Medicine (IOM) report documented that racial and ethnic minorities experienced higher mortality rates, worse health outcomes and were less likely to receive routine procedures. Such practices reduce high quality health and effective, patient-centered, timely and efficient management. Recent national data suggest that some disparities are declining or have been eliminated, but many others have remained the same or even increased in the last few years [National Healthcare Disparities Report, 2008].

Five years ago the Commission to End the Health Disparities was created and formed objectives regarding this subject. The Commission is made up of medical and subspecialities. Their emphasis was on healthcare disparities rather than the more broad, complex landscape of health disparities. Different racial and ethnic groups have poorer health status for many reasons that are not directly linked with healthcare delivery. Even the most active leadership group would not be able to solve such widespread problems as patients who live in poverty, lack transportation, or do not live within reasonable proximity to a physician’s office, while also trying to transform the current system into one that is more culturally sensitive and diverse.

The heart of their mission, the participants decided, was to attack disparities from the perspective they knew best: clinical medicine. Even though an array of social problems contribute to healthcare disparities, physicians can fulfill their roles in society most effectively by providing high-quality care regardless of patients’ racial or ethnic backgrounds. Unequal Treatment also suggested that although health professionals dedicate themselves to providing the highest quality of care possible to every patient, they also may harbour unconscious biases and stereotypes that affect their decision-making and attitudes towards minority patients. For example, the report cited a 1999 study by Schulman et al. that showed physicians were significantly less likely to refer black women for cardiac catheterisation than black and white men and white women, even when they had the same symptoms. Another study cited in the report (vanRyn and Burke, 2000) examined actual clinical encounters and revealed that physicians viewed black patients, in comparison with white patients, as less intelligent, less educated, more likely to abuse drugs or alcohol, and less likely to comply with treatment advice, despite their knowledge of patient income, education and personal characteristics. Based on research on the reverse situation—how patients’ biases and attitudes influence clinical encounters—the IOM report indicated that minority patients perceive higher levels of discrimination in healthcare settings than do non-minority patients.

The development of workshops to help train physicians to understand the impact of healthcare disparities and improve communications with their diverse patient populations was undertaken. More specific recommendations that addressed how to meet the ultimate goal of eliminating racial and ethnic disparities in healthcare were also put forward. Recommendations prioritised the following activities:

Increasing awareness

Educational resource tools were developed in terms of training programmes, videos, speakers’ kits, Internet-based materials, print materials and conferences. A business case model, to educate medical professionals and their employers on workplace changes that contribute to the elimination of disparities, was part of the objective. All medical societies would be encouraged to incorporate disparities elimination into their strategic planning processes. Identification of practical, evidence-based solutions to eliminate disparities in specific conditions, diseases and clinical practices were developed. The Professional Awareness, Education and Training Advisory Committee developed a slide kit and DVD that are used in 3-hour workshops that discuss disparities and offers solutions focussed on improving patient-physician communication. The workshop materials use vignettes of patients from a variety of racial and ethnic backgrounds to break down stereotypes and demonstrate how language and cultural beliefs can affect the delivery of healthcare. Articles and references are provided for background information. The workshop can be tailored for physicians in different specialties and different geographic areas.

Patient / Physician communication and trust

Central to improving communication is sensitising physicians to the fact that nearly half of all adults and the non-English speaking patients in the US may have low health literacy. Developing community networks could help provide patients with understandable, respectful, culturally and linguistically appropriate information.

Leadership for the elimination of disparities

Increased political activity, obtaining cooperation from the Centers for Medicare & Medicaid Services in eliminating disparities, and creating a unified message that includes local-level solutions to address disparities would be key activities.

Cultural competence of physicians

Physicians would have to examine their own attitudes in order to recognise prejudice and avoid or eliminate biased medical decisions. Educational tools, mentoring programmes, and healthcare disparities content in Continuing Medical Education (CME) offerings could help build cultural competence.

A diverse professional workforce

A closer examination of how provider diversity relates to improved patient satisfaction and healthcare outcomes by attracting and recruiting more underrepresented minorities into medical school and other health professions are being examined. Students are provided with information and strategies to gain competitive criteria for successful entry into medical schools.

The creation and maintenance of a diverse workforce changes the cultural experience of non-minority students and exposes those students to a culturally rich learning environment. Incentives such as loan repayment programmes could help reduce physician shortages in underserved communities. The Workforce Diversity Advisory Committee had focussed its efforts on increasing minorities in training programmes by taking an in-depth look at how medical schools’ admissions processes affect minority student enrollment.

A first step is to examine the racial and ethnic composition of admissions and selection committees, and factors involved in their first-tier selection process. Next, a broader assessment would be made of the differences between schools that enroll higher proportions of minority students compared to those with lower minority enrollments.

The Committee also discussed plans to convene key stakeholders—educators, organisations representing minorities, financial groups, government agencies, and the media—in 2006 with the goal of implementing some of the 37 recommendations of the highly regarded report, Missing Persons: Minorities in the Health Professions. This 2004 report was released by the Sullivan Commission on Diversity in the Healthcare Workforce, which was named for its chair, former US Secretary of Health and Human Services Louis Sullivan. Recommendations in the report addressed the underlying reasons why minorities are under-represented in the health professions, in spite of the country’s increasingly diverse population. Another way to increase representation is through the Doctors Back to School (DBTS) programme, was launched in 2002 by the AMA Minority Consortium. Minority physicians and medical students who volunteer in the DBTS programme act as role models by visiting elementary and high schools to talk with students, particularly those in under-represented racial and ethnic groups, about careers in medicine. The programme demonstrates to minority students that a medical career is well within their reach.

Improving quality

Another goal is to help physicians recognise that inconsistent healthcare across different populations is a quality issue, and that disparate care affects patient safety. Physicians should be educated to recognise that cultural competence is related to technical competence. Conditions such as cardiovascular disease, which present greater opportunities for improvement, should be prioritised. Incentives such as discounts on medical liability premiums could enhance the success of quality improvement initiatives such as the use of practice-based assessment tools. Increased minority representation on accrediting bodies such as the Joint Commission also could help improve quality.

Addressing cultural diversity

A core curriculum on healthcare disparities could be developed and made a requirement for medical students and medical school accreditation. Medical students would benefit from more interactions with ethnically and racially diverse faculty and patients. Medical student selection committees should be made aware of provider diversity as an issue of meeting patient needs and increasing patient safety.

Residency and fellowship selection committees should consider the importance of recruiting under-represented minorities. Programme chair meetings should address identification of racial and ethnic disparities and strategies to reduce or eliminate them.

Health disparities / cultural competence education should be required in states with CME requirements. Disparity and diversity issues should be included in certification examinations.

Focussed research

Race, ethnicity and language proficiency should be incorporated into clinical quality performance measures. Healthcare disparities could be an important area for the AMA-convened Physician Consortium for Performance Improvement to consider in its work to develop and test evidence-based clinical performance measures. Additional research in healthcare disparities is needed to refine teaching techniques to improve cultural competence.

Collaborate with other organisations to reduce disparities in care

Collaboration could be established with health plans, Centers of Excellence, health and medical organisations including the American Heart Association and the American Cancer Society, the US Department of Veteran’s Affairs, the Association of American Medical Colleges, the Accreditation Council for Graduate Medical Education, the American Board of Medical Specialties (focussing on its role in recertification), and community and religious organisations that serve minority communities

Interventions and tracking

Creation and dissemination of toolkits. Toolkits are an important intervention that could energise physicians to implement initiatives to monitor and track target diseases. In addition, they could enable state medical societies to offer frontline support. Programmes that improve the image of physicians could help build trust with minority patients. A calendar of organized medicines events that address healthcare disparities could encourage physician participation and act as a planning guide.

Data collection to improve the factors effective to improve that quality improvement initiatives intended to eliminate disparities is needed. Collection of patient data, identifying factors that help or hinder practitioners and organisations in their efforts to eliminate disparities and gathering physician and patient data on race, ethnicity and language groups (Hasnain-Wynia & Baber, 2006, Siegel 2007, IOM) should be collected by health plans, hospitals, large medical group practices and community health centres (Audet et al., Health Affairs 2005; Nerenz et al., HSR, 2006). Instead, many of this type of data are collected in a non-systematic and unreliable way (Hasnain-Wynia & Baber 2006). Among smaller groups of physicians—practices with 1-5 members—there is reason to believe that collecting and using demographic data to track and reduce disparities is even less common.

Implementation of these various objectives throughout the healthcare community allows each of us to take a part in trying to eliminate healthcare disparities by increasing our self-awareness, increasing minority representation in the workforce and collecting data and evidence based medicine to increase the quality-of-care for all individuals.

Author Bio

Mildred M G Olivier is an Associate Clinical Professor at Midwestern University and Assistant Professor at John H. Stroger, Jr., Hospital at Cook County and at Olympia Fields Osteopathic Hospital. She is currently the CEO of Midwest Glaucoma Center. Olivier received her bachelor’s degree from Loyola University and her medical degree from Rosalind Franklin University of Medicine and Science, formerly The Chicago Medical School.

Author Bio

Mildred M G Olivier