Improving Quality and Reducing Disparities: Title and subTitle BreakToward a Common Pathway

Two influential reports from the Institute of Medicine, Crossing the Quality Chasm¹ and Unequal Treatment,² have focused attention on contemporary challenges confronting health care delivery. The first describes a health care system that often fails to provide care based on current science and that is customized to the needs and preferences of individuals. The second summarizes increasing evidence reflecting systematic differences in care associated with patient race, ethnicity, and other factors. Both reports have prompted considerable discussions and debate among the medical profession and the public. However, a growing consensus accepts that a strategy integrating reduction in disparities in quality of care is a coherent and efficient approach to redesigning the US health care system.³

In this issue of THE JOURNAL, the study by Sehgal⁴ addresses a crucial question: Can efforts to improve quality of care for dialysis patients simultaneously reduce disparities in care associated with race and ethnicity? Sehgal analyzed the effects of Medicare-funded quality improvement efforts on white-black and male-female differences in adequacy of dialysis, management of anemia, and nutritional status. Overall, the adequacy of hemodialysis (2-fold improvement) and management of anemia (3-fold improvement) increased significantly. More important, this improvement was accompanied by a 60% to 70% reduction in the white-black gap and the male-female gap for adequacy of hemodialysis. Similar improvements were not observed for nutritional status as assessed by albumin level.

While other studies have confirmed the coexistence of suboptimal quality and racial disparities,^{5 - 6} this is the first study to demonstrate longitudinal improvements in both. By demonstrating synergy between improvement in quality and reduction in disparities, this study strengthens the support for further integration of the 2 strategies.

Disparities improved for some outcomes but not others. As the author correctly points out, "these outcomes require different levels of involvement by clinicians and patients" with anemia management and nutritional status requiring more involvement of the patients. The intervention was designed to influence clinician behavior by measuring, analyzing, and reporting performance to clinicians—it did not focus on patients. It is unlikely that this application of a quality improvement initiative influenced the nature of the patient-physician relationship in a way that would motivate patients and increase their involvement. Perhaps the addition of a patient-centered intervention, designed to increase patient knowledge and participation in care, could improve nutritional status or reduce the gap for anemia management and nutritional status.⁷

Demonstration of the geographic variation in magnitude of disparities for adequacy of hemodialysis provides an opportunity to learn from variations within successful improvement efforts. For example, while a significant majority of states showed racial gaps of 4% or less, a significant minority had a racial gap of 13% or more. In addition, state performance on reducing the racial gap did not accord with performance on reducing the gap between the sexes. These discrepancies suggest that states need a clearer understanding of the success they have achieved and how they can apply lessons learned in successful areas to less successful ones.

This study by Sehgal does not report on the gaps in dialysis care for other racial/ethnic groups. The Centers for Medicare and Medicaid Services enrollment database has a 97% sensitivity for identifying white and black patients, but its sensitivity is 60% for identifying other racial/ethnic groups, including Hispanics, Asians, and Native Americans.⁸ The increasing demographic diversity within the US population will require additional efforts to identify other ethnic groups reliably.

The analysis by Sehgal was possible because the Medicare enrollment files include patient race and ethnicity. However, the collection of racial and ethnic data by physicians and health care organizations, purchasers, and plans is not a universal practice in the United States. Many individuals in the United States, including those who receive privately financed health care as well as beneficiaries of publicly funded programs, are in health plans that do not collect this information. Indeed, some systems have a specific policy not to collect such data.^{9 - 10} Moreover, it is likely that many data sources, such as hospital discharge abstracts, do not necessarily include patient-identified race and ethnicity.

While an increasing number of organizations are involved in some quality improvement efforts, there is no consensus regarding the value of assessing and stratifying reported performance by racial/ethnic status.¹¹ Perceived barriers to the routine collection of race/ethnicity data include cost of data collection, concerns about data quality, lack of legal authority, concerns about patient privacy and confidentiality, recognition of the potential for misuse, questions about timing of data collection, and concerns about public reporting and accountability.^{11 - 12} In addition, even with available data, stratifying performance at the level of an individual institution is often not feasible due to limited sample size. Stratified reports may only be possible at a level of aggregation above that of any single institution, for example, for a region or state.

Although much needs to be done, several public- and private-sector organizations are addressing these barriers.^{11 - 12} For instance, some health care plans collect race/ethnicity data for specific quality improvement activities.¹¹ Other health plans propose that this information supports the development of marketing strategies to minorities,¹¹ a rapidly growing segment of the population. The understanding of how, when, and for whom quality improvement efforts work should be enhanced by a collaboration between the Health Resources and Services Administration and the Agency for Healthcare Research and Quality.¹³ This initiative involves evidence-based, disease-specific quality improvement efforts to examine which efforts to improve quality and reduce disparities in care for individuals are successful and to determine the contextual factors that predict improved outcomes.

It would be reassuring to note that the results reported by Sehgal conclude that serious efforts to improve quality of care will simultaneously reduce disparities in care. In view of numerous studies^{3 ,5 ,14 - 17} revealing both significant gaps in quality of care as well as substantially larger gaps associated with race, ethnicity, and other patient characteristics, additional studies that explore the combined impact of quality improvement efforts are warranted.

As the findings by Sehgal show, a generic quality improvement may concurrently reduce racial/ethnic disparities in care, but results may be inconsistent. Appropriate collection and use of racial and ethnic data are essential to evaluate progress in minimizing inequality in quality of care. Given the challenges involved in addressing both quality improvement and reductions in disparities, it is important to realize what will be lost if this is not done. Available resources for quality improvement may be invested most efficiently by targeting efforts to those subgroups at highest risk of receiving poor care. In addition, differences in performance associated with race, ethnicity, or other patient characteristics may provide important insights about the relative contributions of biological, social, and health care factors to observed differences in disease course. For example, differences in breast cancer mortality for black women are thought to be only partially attributable to differential access to effective care.^{18 - 19}

The rising tide of quality improvement may lead to improvements for all patients. But failure to examine the distribution of benefits may also wash away undiscovered information about the intersections of disease, individual characteristics, and health care delivery that are essential for eliminating disparities in health care and continuing to develop effective treatments.