Quality of Care/Patient Safety

• Hispanics tend to give more positive ratings of care than whites.

  Researchers examined how Hispanic ethnicity and insurance status (Medicaid vs. commercial managed care) affect the use of the 0-10 rating scales in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Previous studies have shown that Hispanics report care that is similar to or less positive than non-Hispanic whites but give more positive ratings of care, and that blacks and Hispanics are more likely than whites to use the extreme responses in a rating scale. In this study, Hispanics were more likely than whites in commercial plans to give the highest rating of "10," but they often gave ratings of 4 or below relative to an omitted category of "5" to "8." The researchers call this "extreme response tendency," which is a tendency to respond systematically to questionnaire items on some basis other than what the items were intended to measure. They suggest pooling responses at the top (9 and 10) and bottom (0 to 6) of a 10-point scale when making racial/ethnic comparisons.

  Source: Weech-Maldonado, Elliott, Oluwole, et al., Med Care 46(9):963-968, 2008 (AHRQ grant HS11386).

• Elevated hospitalization rates for elderly blacks suggest problems with the quality of outpatient care.

  This study found that elderly blacks in North Carolina are hospitalized for ambulatory care-sensitive conditions (ACS)—such as complications related to diabetes or exacerbation of asthma symptoms—more often than elderly whites, suggesting poorer outpatient quality of care among blacks. The researchers used 1999-2002 Medicare data to examine differences in hospitalization rates for eight ACS conditions: bacterial pneumonia, congestive heart failure, diabetes, chronic obstructive pulmonary disease, dehydration, urinary tract infection, angina, and asthma. Blacks were hospitalized at higher rates than whites for five of the eight conditions.

  Source: Howard, Hakeem, Njue, et al., Public Health Rep 122:362-372, 2007 (AHRQ grant HS13353).

• Certain aspects of medical care are critically important to female Somali refugees newly arrived in the United States.

  In-depth interviews with resettled Somali women in Rochester, NY, revealed differences in spoken language, degree of acculturation, and literacy. They described the elements of U.S. primary care most important to them, including ease of accessing the health care system, availability of interpreters, a trusting relationship with clinicians, and the availability of female clinicians, especially for gynecologic exams.

  Source: Carroll, Epstein, Fiscella, et al., Patient Educ Counsel 66:337-345, 2007 (AHRQ grant HS14105).

• Content of primary care visits does not differ based on the racial composition of physicians' practices.

  Researchers analyzed the content of office visits using 1997-2002 survey data and found that based on commonly performed procedures, primary care physicians with a large proportion of black patients do not provide inferior care compared with their colleagues who have a small proportion of black patients. Procedures ranged from Pap smears and vision screening to cholesterol and blood pressure checks, diet and exercise counseling, and mammography screening. A relatively small proportion of providers (24 percent of physician practices) provided 80 percent of all primary care visits by black patients.

  Source: Fiscella and Franks, Am J Med 119:348-353, 2006 (AHRQ HS10910).

• Race/ethnicity found to be associated with hospital discharge against medical advice.

  According to this study, blacks are twice as likely as whites to be discharged against medical advice (DAMA) at hospitals in three States (California, Florida, and New York), Hispanics also have a higher rate of DAMA, and Asian and other ethnic groups are less likely than whites to be DAMA. Patient risk factors for DAMA included younger age, male sex, nonelective admission, Medicaid insurance, no insurance, and fewer coexisting medical conditions. Hospital risk factors for DAMA included location in large urban areas, higher ratio of minority patients and patients with Medicaid coverage, and highest and lowest degree of specialization.

  Source: Franks, Meldrum, and Fiscella, J Gen Intern Med 21:955-960, 2006 (AHRQ grant HS10910).

• Blacks and Hispanics receive poorer quality of care than whites but rate their contact with providers more positively.

  This study found that blacks received significantly worse care than whites for 68 percent of clinical quality measures and 35 percent of care access measures, while receiving better care for 10 percent of the access measures and none of the quality measures. Hispanics received significantly poorer care compared with whites for 50 percent of quality measures and 90 percent of access measures, while receiving better care for 11 percent of quality measures and 3 percent of access measures. Yet across the board, blacks and Hispanics were more likely than whites to positively rate their care. They reported that their providers always listened carefully, explained things in a way they could understand, and showed respect for what they had to say.

  Source: Dayton, Zhan, Sangl, et al., Am J Med Qual 21(2):109-114, 2006 (AHRQ Publication No. 06-R049)* (Intramural).

• Patients who are poor and/or black may believe that a positive self-presentation can affect the quality of their medical care.

  This study found that poor and black patients are more likely than white and more affluent patients to present themselves as positively as they can by being friendly and wearing nice clothes to improve their chance of obtaining optimal care. The researchers used data from a 2004 survey that asked patients how important they thought it was to wear nice clothing to an appointment, look very clean, arrive on time, be friendly with the doctor and office staff, let the doctor know that they cared about their health, and show that they were intelligent to get the best treatment possible at the doctor's office. Blacks, on average, rated positive self-presentation as more important than whites. Those with less education and lower income also rated self-presentation as more important than people with more education and higher income.

  Source: Malat, van Ryn, and Purcell, Soc Sci Med 62:2479-2488, 2006 (AHRQ grant HS13280).

• Black patients tend to ask fewer questions of their doctors and receive less information than other patients.

  Researchers analyzed audiotapes of 137 patients receiving initial treatment recommendations in oncology or thoracic surgery clinics at a large Veterans Affairs Medical Center between 2001 and 2004. They found that black patients with suspicious or cancerous lung masses were less likely than other patients to bring a companion to physician consultations, and they received significantly less information and made fewer contributions to the discussion compared with white patients. Also, communication issues were most prominent in interactions between patients and doctors of different races. The researchers conclude that less participation by black patients in medical discussions with their doctors—rather than race per se—may be why they receive less information from the doctors than white patients.

  Source: Gordon, Street, Sharf, and Souchek, Cancer 107(6):1313-1320, 2006 (AHRQ grant HS10876).

• Consistent use of interpreters improves care quality and access for Hispanic and Asian patients.

  Hispanic and Asian/Pacific Islander parents who always use interpreters during their children's outpatient medical visits report significantly better care access and quality than their counterparts who don't use interpreters, according to this study. These parents also report better service from their health plans and better care on several dimensions when compared with health plan members who do not use interpreters. Researchers analyzed survey data on members enrolled in the California State Children's Health Insurance Program in 2000 and 2001. A total of 26,671 members of 26 health plans completed the surveys.

  Source: Morales, Elliott, Weech-Maldonado, and Hays, Med Care Res Rev 63(1):110-128, 2006 (AHRQ grant HS09204). See also Green, Ngo-Metzger, Legedza, et al., J Gen Intern Med 20:1050-1056, 2005 (AHRQ grant HS10316).

• English-speaking ability affects reports of quality of care problems for colorectal cancer patients.

  Blacks, Hispanics, Asian/Pacific Islanders, and non-English-speaking white patients are significantly more likely than English-speaking white patients to report problems in quality of care for colorectal cancer, according to this study. These results are based on survey responses of 1,067 patients with colorectal cancer in northern California. Researchers focused on questions about coordination of care, psychosocial care, access to care, and availability of information about treatment. Problems with coordination of cancer care were most strongly correlated with lower ratings of overall quality of care.

  Source: Ayanian, Zaslavsky, Guadagnoli, et al., J Clin Oncol 23(27):6576-6586, 2005 (AHRQ grant HS09869).

• Racial disparities in care vary widely among Medicare plans.

  Researchers used outcome measures for blood glucose, cholesterol, and hypertension to assess 151 Medicare health plans in overall quality and racial disparities between 2002 and 2004. They found that the plans varied substantially in both overall quality and racial disparities on each of the outcome measures, but quality and racial disparity were not correlated. Overall, 21 to 41 percent of enrollees did not achieve the relatively liberal goals for blood pressure, glucose, and cholesterol control. Clinical performance on these measures was 7 to 14 percent lower for black enrollees compared with their white counterparts. For each measure, more than 70 percent of the disparity was due to different outcomes for black and white enrollees in the same health plan rather than selection of black enrollees into lower performing plans.

  Source: Trivedi, Zaslavsky, Schneider, and Ayanian, JAMA 296(16):1998-2004, 2006 (AHRQ grants HS10803 and T32 HS00020).

• Studies document persistent disparities in health care associated with women's race, ethnicity, income, and other factors.

  A commentary and five papers were prepared for a special issue of the journal, Women's Health Issues. They address disparities in the quality of preventive and chronic care received by women, including minority women. The first paper introduces the special issue. Other papers focus on differences by ethnic group in quality of care for heart attack and heart failure, the quality of diabetes care, women's health care use and expenditures, preventive health examinations, and quality of care for older women of all races.

  Source: See Women's Health Issues 16(2), March 2006 (Intramural).

• Perforated appendix occurs most often among minority and Medicaid-insured children.

  Perforated appendix usually results from delayed diagnosis and treatment, and it disproportionately affects both minority and Medicaid-insured children, according to this study. Researchers analyzed data from AHRQ's KID database (pediatric hospitalizations in 22 States) and found that ruptured appendix occurred in one-third of the 33,183 children hospitalized for acute appendicitis in 1997. Black and Hispanic children were much more likely than white children (24 percent and 19 percent, respectively) to have perforated appendix. Perforation also was 30 percent more likely among Medicaid-insured children compared with privately insured children.

  Source: Smink, Fishman, Kleinman, and Finkelstein, Pediatrics 115(4):920-925, 2005 (AHRQ grant T32 HS00063).

• Study finds underuse of anticoagulation medications by Japanese patients following orthopedic surgery.

  Practice guidelines recommend prophylactic use of anticoagulants such as heparin or warfarin after major orthopedic surgery to decrease the risk of blood clots in the leg (deep vein thrombosis, DVT). Despite these recommendations, use of these medications is low, especially among Japanese patients. Researchers studied the medical records of 1,811 adults who underwent hip replacement surgery, hip fracture surgery, or total knee replacement at a hospital in Hawaii and found that only half of the patients studied received anticoagulants to prevent DVT following their surgery. Japanese patients were only 70 percent as likely as white patients to receive prophylactic therapy with anticoagulants, but this disparity was not found with other ethnic groups.

  Source: Gelber and Seto, Int J Qual Health Care 18(1):23-29, 2006 (AHRQ grant HS11627).

• Acculturation, length of relationship, and physician ethnicity influence Japanese American's trust of doctors.

  According to this study, both English-speaking and Japanese-speaking Japanese Americans trust their doctors more than Japanese people living in Japan, but several factors affected the degree of their trust. A survey of 539 English-speaking Japanese Americans, 340 Japanese-speaking Japanese Americans, and 304 Japanese people living in Japan revealed that greater acculturation, greater religiosity, less desire for autonomy, and longer physician-patient relationships were associated with increased trust. Japanese Americans also trusted Japanese physicians more than they trusted other physicians.

  Source: Tarn, Meredith, Kagawa-Singer, et al., Ann Fam Med 3(4):339-347, 2005 (AHRQ grant HS07370).

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Reducing Disparities

• Payers and policymakers can incorporate disparity reduction goals into pay-for-performance strategies.

  One concern about pay-for-performance strategies is their potential to have a negative impact on racial/ethnic disparities in care. These researchers suggest ways that payers and policymakers can incorporate disparity reduction goals into existing pay-for-performance programs. Such strategies should include performance measures that target disparities, and they should reward performance improvement in addition to achievement. Also, payers and health care organizations should tie pay-for-performance incentives to disparity reduction by stratifying quality of care data according to racial/ethnic groups.

  Source: Chien and Chin, J Gen Intern Med 24(1):135-136, 2009 (AHRQ grant HS17146).

• Older age, less education, lack of time, and other factors limit enrollment in research studies.

  The researchers sought to determine what factors affected enrollment in two studies of literacy and health-related quality of life for 651 English-speaking and 487 Spanish-speaking ambulatory cancer patients. The purpose of the studies was to develop and validate a bilingual multimedia touchscreen program for patients with differing computer and literacy skills. Spanish-speaking patients enrolled at a much higher rate than English-speaking patients (91 vs. 65 percent, respectively). For English-speaking patients the barriers to enrollment were older age and lower educational levels. For both groups of patients, lack of time and recruiting from private hospital sites were barriers.

  Source: Du, Valenzuela, Diaz, et al., Stat Med 27:4119-4131, 2008 (AHRQ grant HS10333). See also Napoles-Springer, Santoyo, and Stewart, J Gen Intern Med 20:438-443, 2005 (AHRQ grant HS10599).

• Pediatricians show less implicit race bias than others.

  Researchers surveyed academic pediatricians about their implicit and explicit racial attitudes and stereotypes and found that pediatricians are less likely to harbor attitudes that favor white Americans than other physicians and individuals. Most of the surveyed pediatricians were white (82 percent), and 93 percent were American-born. The researchers found no link between pediatricians' implicit racial attitudes and stereotypes and quality of pediatric care.

  Source: Sabin, Rivara, and Greenwald, Med Care 46(7):678-685, 2008 (AHRQ grant HS15760).

• AHRQ Director calls for more research to understand and eliminate disparities.

  In this commentary, AHRQ Director Carolyn M. Clancy, MD, discusses the need for expanded research to understand and close gaps and disparities in care and for physician leadership to assure that the care provided is evidence-based, patient-centered, effective, consistent, and equitable.

  Source: Clancy, Arch Intern Med 168(11):1135-1136, 2008. See also Clancy, J Health Care Law Policy 9(1):121-135, 2006 (AHRQ Publication No. 07-R039)* (Intramural).

• More data are needed to identify health care disparities among American Indians and Alaska Natives.

  AHRQ's National Healthcare Disparities Report (NHDR) is an annual report to Congress on racial, ethnic, and socioeconomic disparities in U.S. health care. Conditions covered include cancer, diabetes, end stage renal disease, heart disease, respiratory disease, mental health, and substance abuse. Due to limited data availability (particularly patient safety data), less than half of the measures of quality and access to care tracked in the NHDR can be used to assess disparities among American Indians and Alaska Natives. In this article, AHRQ researchers describe data limitations for all ethnic and racial groups and discuss the specific constraints on analyses posed by the paucity of data on American Indians and Alaska Natives.

  Source: Moy, Smith, Johansson, and Andrews, Am Indian Alsk Native Ment Health Res 13(1):52-69, 2006 (AHRQ Publication No. 06-R038)* (Intramural).

• Practice-based research can contribute to reduction of racial disparities.

  The authors discuss the state of disparities research and the limited progress to date in reducing disparities. They review 12 promising strategies that could substantially increase the impact of practice-based research on eliminating health disparities in the United States. These range from using diverse research teams and partnerships within communities to triangulation interventions involving practice, patient, and community.

  Source: Rust and Cooper, J Am Board Fam Med 20:105-114, 2007 (AHRQ grant HS13645).

• Enhancing cultural competence of clinicians and clinics may reduce care disparities.

  Culturally competent clinicians are more likely to understand the language, values, and beliefs of the racial and ethnic groups they serve and to have the attitudes and skills to convey their respect and understanding in the care they provide. This study is the first to link provider cultural competence with the cultural competence of the clinics in which they work. Researchers found that culturally competent clinicians are more likely to work in clinics that have a higher percentage of minority staff, offer cultural diversity training, and provide culturally adapted patient education materials. Enhancing the cultural competence of both clinicians and clinics may be a synergistic approach to reducing health care disparities, according to the researchers. They surveyed 49 providers from 23 clinics in Baltimore, MD and Wilmington, DE.

  Source: Paez, Allen, Carson, and Cooper, Social Sci Med 66:1204-1216, 2008 (AHRQ grant HS13645). See also Hobson, Avant-Mier, Cochella, et al., Ambul Pediatr 5(2):90-95, 2005 (AHRQ grant HS11826).

• Minority status and early life experiences prompt physicians' involvement in reducing care disparities.

  According to this study, many of the physicians most committed to reducing health care disparities are themselves minorities or had early childhood experiences with minorities. The researchers conducted in-depth interviews with a group of 14 physicians who had high engagement scores on an earlier survey of 836 primary care doctors. Half of the study physicians identified themselves as minorities, and the remainder related extensive personal experiences with minorities. Many physicians expressed frustration with some key barriers to equitable care, including language barriers, resource limitations, lack of patient education, and low patient empowerment. To reduce disparities, they suggested that physicians actively engage and take more time with patients, treat them as equals, and exhibit more understanding of patients' backgrounds and needs.

  Source: Vanderbilt, Wynia, Gadon, and Alexander, J Natl Med Assoc 99(12):1315-1322, 2007 (AHRQ grant HS15699).

• American Indian health advocates can learn to develop multimedia health promotion projects for rural communities.

  American Indian health advocates often know best what services their communities need and, with technical training and support, they could develop multimedia health care information projects to address those issues (e.g., teen pregnancy, alcoholism, and diabetes). The Native Telehealth Outreach and Technical Assistance Program equipped and trained nine health advocates from a variety of backgrounds, including an HIV counselor, a registered nurse, and an elementary school teacher. Participants were coached by operational and technical mentors and had access to a state-of-the-art multimedia facility to develop their educational projects; eight of the nine participants had developed projects at the end of the 18-month project. Examples include an interactive CD-ROM on the effects of alcohol and drugs for use in elementary schools, an educational video on hepatitis C, and a Web site and brochure campaign on birth control methods available to the tribal community.

  Source: Dick, Manson, Hansen, et al., Am Indian Alsk Native Ment Health Res 14(2):49-66, 2007 (AHRQ grant HS10854).

• Research collaborative aims to reduce disparities affecting tribal nations in Montana and Wyoming.

  A collaborative consortium has been formed to reduce health disparities affecting Montana and Wyoming tribal nations, while promoting behavioral and lifestyle changes among these groups. The consortium has undertaken activities to establish a research infrastructure and develop a targeted research agenda that addresses tribally identified priority health issues, such as hepatitis C, West Nile virus, and methamphetamine use.

  Source: Andersen, Belcourt, and Langwell, Govern Politics Law 95(5):784-789, 2005 (AHRQ grant HS14034).

• Strategies to improve health literacy for diverse populations are critical to reducing health disparities.

  Racial/ethnic minority adults are more likely than white adults to have limited health literacy, and strategies to improve health literacy for this group must be relevant to the individual's language and culture. A low score on a health literacy assessment could be due to low literacy, limited English proficiency, or lack of familiarity with Western health terms and concepts. The researchers recommend that clinicians integrate health literacy techniques—such as having patients explain back to clinicians what they have been told, using culturally competent communication practices, and respecting culturally dictated family involvement in medical decisions—to overcome barriers related to literacy, language, and cultural differences.

  Source: Andrulis and Brach, Am J Health Behav 31(Suppl 1):S122-S133, 2007 (AHRQ Publication No. 07-R079)* (Intramural). See also Guerra and Shea, Ethn Dis 17:305-312, 2007 (AHRQ grant HS10299).

• Education, income, and net worth explain more health disparities than health behaviors and insurance coverage.

  Public health initiatives to reduce racial/ethnic disparities that promote changes in individual health behaviors such as smoking and overeating and increasing rates of insurance coverage will result in only modest decreases in health disparities, according to this study. The researchers analyzed data from a nationally representative survey of U.S. adults aged 51 to 61 in 1992 and found that accounting for education, income, and net worth reduced disparities in self-repored overall health for blacks and English-speaking Hispanics to nonsignificance. In contrast, accounting for health insurance and health behaviors explained little of the racial/ethnic differences in health outcomes.

  Source: Sudano and Baker, Soc Sci Med 62:909-922, 2006 (AHRQ grants HS10283 and HS11462).

• AHRQ's Medical Expenditure Panel Survey (MEPS) can help to explain racial/ethnic disparities in health care.

  These researchers demonstrate the capacity of MEPS for use in exploring disparities in health care. To demonstrate the usefulness of MEPS, they linked data from the 2000 and 2001 MEPS with detailed neighborhood characteristics from the Census Bureau and local provider supply data from the Health Resources and Services Administration and showed that insurance status and socioeconomic differences explained a significant portion of the disparities in care.

  Source: Kirby, Taliaferro, and Zuvekas, Med Care 44(5 Suppl):64-72, 2006 (Intramural).

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