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Highlights and Implications from the Findings of the National Healthcare Quality Report and Disparities Report

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Remarks by Carolyn Clancy, M.D., Director of the Agency for Healthcare Research and Quality

The Office of Minority Health National Leadership Summit on Eliminating Racial and Ethnic Disparities in Health, January 9, 2006

Thank you, Garth, for the kind words and thank you for the opportunity—and the honor—to be a part of the Office of Minority Health's National Leadership Summit on Eliminating Racial and Ethnic Disparities in Health. I've been looking forward to this event for a long time, and the chance to see so many of my friends and colleagues who have been working so hard on the issues being addressed at this summit.

One of the most valuable things about a being at a summit is perspective—having a clear vantage point to look at where we've come from, to look around and see where we stand today, and to look ahead to see where we're going. With that in mind, I'd like to focus on three areas this morning:

  • The foundational role of the Heckler Report in bringing us to where we are today.
  • AHRQ's release today of the third annual National Healthcare Quality Report and Disparities Report, and how we're doing as a nation to improve quality and eliminate disparities.
  • And finally, I'd like to talk to you about the opportunities we have to use these measures, and build on a range of promising initiatives, to improve health outcomes for all Americans.

It is altogether fitting and proper that this summit is commemorating the 20th anniversary of the "The Secretary's Report on Black and Minority Health," presented by then Secretary of Health and Human Services, Margaret Heckler.  Before that, she was my congresswoman from the Commonwealth of Massachusetts. In fact, a strong case can be made that this summit, and the National Healthcare Quality and Disparities Reports, owe their origins to the legacy of the Heckler report, and the awareness it raised.

In historic terms, the 1980s were not that long ago.  Recollections of key events that led to the development of the Heckler Report are still vivid. There are people here today who contributed to the report and remember standing in Secretary Heckler's conference room, when she was briefed by staffers on a draft of the 1984 "Health-United States" report. After reviewing the report, which contained presentations of very statistically different data under the headings "White", "Black" and "Total,"  Secretary Heckler asked, "Why are these differences so consistent and so large?"  Her briefers were momentarily taken aback.  They paused for a moment and then someone explained, "It's always been that way."

But thanks to the Heckler Report, we finally had a clear starting point and the outline for a roadmap to change things.  Our national dialogue on disparities began to be informed by research, and supported by a growing commitment, not only measure disparities, but to find out why they occur and how they can be eliminated.

I have been fortunate, as a health services researcher, to have many opportunities to study the causes, effects and implications of racial, ethnic and socioeconomic disparities in American health care. But as a medical doctor, my interest in wanting to understand and eliminate disparities was inspired by my experience with patients—and I remember one in particular.

Early on in my residency in Massachusetts, I was working in the emergency department and saw a female patient who was suffering from severe abdominal pain.  She didn't speak English, and had a friend translating my questions into Spanish.  I kept asking her, in as many ways as I could, "are you taking antacids?"  I went up and down the list of over-the-counter brands and she kept shaking her head "no, no, no".

She finally returned home to wait for her lab tests.  When the tests came in, it was clear that she needed to come back to the hospital.   However, she did not have a phone. So the next morning, after my shift, I went to her home with a Spanish-speaking nun to ask her to return to the hospital. And from the moment we walked in her door, we saw bottles and bottles of Mylanta everywhere.  There must have been over 40 bottles in her home, visible to me.

That experience gave me first-hand knowledge about how barriers in language and culture can stand between a patient and the care they need, despite everyone's best intentions.  There I was, with all the resources of a teaching hospital, but unable to get to the underlying issue.  It was frustrating, but it motivated me, as it has so many clinicians and researchers, to study the factors that create disparities.

Today, we have ways to measure the quality of patient-provider communication, as well as a broad array of other measures—179 in all—that measure quality and disparities in four key areas: effectiveness, patient safety, timeliness and patient centeredness.  And you will find them all in the third annual National Healthcare Quality and Disparities Reports, which were literally printed over the weekend.  In fact, they arrived with me this morning. So, let's take a look at some of the highlights and implications of the 2005 Reports.

During the last year, the overall quality of U.S. health care improved at the rate of 2.8 percent, the same rate of improvement shown in last year's National Healthcare Quality Report. In 44 core quality measurement categories, 23 improved, 19 were unchanged and only two became worse. Nevertheless, the 2005 report shows that there has been much more rapid improvement in some measures, especially where there have been focused efforts to improve performance. For example, measures for heart attack, heart failure and pneumonia showed an annual improvement of 9.2 percent.  These are priority areas for Medicare, where hospitals have received special help from Medicare's Quality Improvement Organizations.

The 2005 National Healthcare Disparities Report finds that significant disparities between whites and minorities continue, with some signs of improvements. In measures related to the quality of care, more racial disparities were narrowing than widening. For example, rates of late stage breast cancer decreased more rapidly among black women than among white women resulting in a narrowing of the disparities. Treatment of heart failure improved more rapidly among American Indian Medicare beneficiaries than among white Medicare beneficiaries. 

Despite these trends, blacks received poorer quality of care than whites in 43 percent of the core measures, and American Indians and Alaska Natives received poorer quality of care than whites in 38 percent of measures. In access to care, we saw reductions in most racial disparities affecting blacks, Asians, and American Indians and Alaska Natives. 

However, this trend has been reversed for Hispanics, where we saw disparities in quality and access to care growing wider in a majority of areas. Only 41 percent of quality disparities were narrowing for Hispanics, while 59 percent were growing larger.  The report also indicated that disparities were growing for most measures related to access. For example, the quality of diabetes care declined among Hispanic adults as it improved among white adults. In addition, the quality of patient-provider communication (as reported by patients themselves) declined from among Hispanic adults as it improved among white adults. Access to a usual source of care increased more slowly among Hispanics than among whites.

Overall, the Disparities Report shows that low-income people, regardless of race or ethnicity, experienced many of the largest disparities health care quality and access.

In many areas, we know the specific treatment steps and procedures to take for quality improvement.  We know what to do.  The challenge continues to be make sure everyone in the health care system knows what to do, and is making it part of their everyday practice. We've seen that public reporting is a powerful tool for improvement. The public reports coming from Medicare's Hospital Quality Initiative have been very useful in this area.

Another great example of the power of the spotlight was reported last year in the New England Journal of Medicine.  The study examined trends in the quality of care and racial disparities for Medicare beneficiaries in managed care plans. The health plans were required to report on the quality of care they provided according to the HEDIS [Health Plan Employer Data and Information Set] measures.  When the study began, the early data indicated that blacks received of lower quality care than whites. However, after seven years of publicly reporting performance through HEDIS, the health plans' clinical performance improved substantially on all measures.  Gaps in quality associated with patient race narrowed in seven of the nine measures.  And because of public reporting by nursing homes, the 2004 National Healthcare Quality Report indicated that their quality is improving steadily.

We have a mixed record of success in improving quality of care in our Nation and reducing health care disparities.  While we find improvements in quality and access on a wide front, it is inconsistent, and the need for action to improve quality of care for all Americans is as great as ever. In addition, what we're seeing is an enormous opportunity not only to close the gap in health care disparities, but to improve the overall health of all populations. These are inextricably linked. 

Too much of a focus on specific populations or measures can take our eyes off of the big picture.  We need to be bold, ambitious and imaginative as we set improvement goals for all of our citizens. The bottom line is that we are seeing modest improvement in quality and an overall narrowing in disparities for most racial groups.  But much more is needed—no measures were at optimal levels for anyone.  This is especially for Hispanics, where we need to turn the trend around.

So what are some of the implications of these reports?  How can we use these measures, build on the progress we're making, and keep moving forward?

As a researcher, I can appreciate how far we've come during the last few years we've worked on these reports.  Our knowledge base is growing and our measurement tools are getting more powerful. But as these tools get better, we recognize that we still need to get better information.  There are still significant gaps in reporting racial and ethnic disparities at the state level, and at the health plan level.

In particular, we need much better information at all levels on Hispanic sub-groups, especially related to language and dialect. We also need to collect and analyze more racial and ethnic data from health plans and insurers so this data can be used to improve patient care. 

According to a 2004 report from America's Health Insurance Plans, almost half of health plan enrollees surveyed belong to a health plan that does not collect data on race and ethnicity.  This information gap needs to be closed if we are going to fully understand the scope of this challenge. 

We also need to include the study of priority populations in more of our research to increase our knowledge base.  At AHRQ we're addressing this need by asking all of the researchers we support to consider and include priority populations in their studies wherever feasible.

Good data and good measurements are important, because what you can't measure, you can't change.  We need benchmarks and signposts along the way to show how we're doing.  But reports alone cannot produce results. But we can't wait. We need to do what we can to eliminate disparities now.  We need to design and test interventions that address the disparities we find.  We need to change our focus from documenting gaps in care to finding ways to close the gap. Moreover, our efforts to do so are likely to yield additional scientific insights.

The key to these efforts is collaboration, and there are many great examples of partnerships out there.  One of the most far-reaching is the National Health Plan Collaborative to Reduce Disparities and Improve Quality in Diabetes Care. 

Nine of the nation's largest health insurance plans have joined together to improve the capacity to collect and analyze data on race and ethnicities.  These data are linked to quality measures, and they are developing quality improvement interventions to close gaps in care. Along with the Robert Wood Johnson Foundation, the Center for Health Care Strategies and the Institute for Healthcare Improvement, AHRQ is helping to fund and guide this collaborative. It is doing vitally important work to close the gap in the quality of diabetes care for African Americans, Hispanics and Native Americans. 

As you may know, these populations have higher rates of diabetes-related complications —in some cases as much as 50 percent greater than the total population. One of the most impressive aspects of this collaboration is that the leaders of these health plans came to us even before the first National Healthcare Disparities Report was published. 

A unique feature of this collaborative is that the plans commit to improve and share their results with each other.  For them this is not 'research' or a 'demonstration' but core business.  It's a model for an action-oriented approach to a pervasive problem in health care.

The bottom line is that when it comes to disparities, we simply don't have the luxury or the time to fund long-term 'definitive' studies.  As public and private entities work together and share ideas and resources, we can test different approaches, learn as we go, and share what we learn.

The growing commitment by health insurers and employers, and the work of many disparities-related collaboratives are making a difference, not only nationally, but locally.   It's at the local and community level where we have the most opportunity to make lasting progress.  And as more organizations learn about these tools, it's no longer a matter of "pushing" them out to the field, but meeting the increased "pull" or demand, and that's a challenge we eagerly accept.

That's why we support community-based research and share our research tools at the county and state level, and work with so many local health plans and non-governmental organizations.  It's why we work with HRSA and have seen so much success with its initiatives. We know that it is essential to have good measures and reporting tools at the national level, so we can inform policy, see trends, and know where we're going as a country. 

But for the average person, on a day-to-day basis, population level analyses at the national or State levels are pretty abstract.  To paraphrase another popular saying in this town, "All health care is local".

Communities that use the powerful measurement tools we have developed for the National Healthcare Quality and Disparities Reports consistently are going to be able to gather disparities-related information much more efficiently than we can at the Federal level.  It will be much more meaningful to them.

Through these reports, and the resources behind them, we're dedicated to making these standardized tools available at the grass roots level for the benefit of each community, and for the benefit of the nation as a whole. We're going to do as much as we can to promote the National Healthcare Quality and Disparities Reports. We will raise awareness and continue the sense of urgency and purpose to all the work being done to eliminate disparities across our country.

We can never underestimate the importance of awareness for this issue, or fail to see the importance of disparities in personal terms and its impact on the fabric of American communities.  Disparities are more than facts and figures.  They have a human face, a uniquely American countenance.

So where do we go from here?  Where are we on the journey to our common destination, an America where health outcomes are getting better for all of our citizens?  From the standpoint of this summit, I can see four milestones on our roadmap for quality improvement and the elimination of disparities.

The first milestone was the Heckler Report and developing the research wherewithal and commitment to measure disparities.

The next milestone, in my opinion, was an AHRQ-supported study that came out of Georgetown University in 1999.  In this study, physicians watched videos of white and minority actors portrayed patients with identical symptoms for a heart problem.  They were less like to prescribe evidence-based diagnostic procedures for older African American women. As you can imagine, the results of this study had an enormous impact within the physician community, and started a very productive dialogue.

The third milestone is actually a series of many milestones in health services research, reflecting our increased commitment as a nation to study the causes of disparities, and target more research funding in this area. 

And the fourth milestone is being built all around us, through public-private collaboration, as we translate our growing body of research into practice, and develop effective interventions to eliminate disparities. Our goal is to reduce disparities in health by providing the highest possible quality of care for all of our citizens, and with every step we take together, we're getting closer to this goal, and we can never lose sight of this common destination.

Whether you study the reports, study the faces of our fellow citizens or study your own heart, it becomes clear that eliminating the disparities in health care is one of the most important things we can do as a nation to improve the overall quality of American health care. 

To make further improvements in quality of care and respond to a more demographically diverse population, we need to bridge the gap on disparities.  And because of the energy and enthusiasm of the people in the room, and the people you represent, I'm confident we can do it.

Now more than ever, the quality of healthcare is intertwined with the commitment to eliminate disparities.  It reminds me of something Dr. Martin Luther King, Jr. said many years ago, but seems to be even more appropriate for today's discussion. Dr. King said, "We are caught in an inescapable network of mutuality, tied to a single garment of destiny.  Whatever affects one directly affects all indirectly."

In this spirit of connectedness and cooperation, let us continue our work, so that the day will come when all we need is a National Healthcare Quality Report, and the Disparities Report is no longer necessary.  Thank you very much.

Current as of January 2006


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