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Achieving Health Equity: Closing The Gaps In Health Care Disparities, Interventions, And Research Purnell, Tanjala S; Calhoun, Elizabeth A; Golden, Sherita H; Halladay, Jacqueline R; Krok-Schoen, Jessica

L; Appelhans, Bradley M; Cooper, Lisa A . Health Affairs ; Chevy Chase  Vol. 35, Iss. 8,  (Aug 2016): 1410-

1415.

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ABSTRACT (ENGLISH) In the United States, racial/ethnic minority, rural, and low-income populations continue to experience suboptimal

access to and quality of health care despite decades of recognition of health disparities and policy mandates to

eliminate them. Many health care interventions that were designed to achieve health equity fall short because of

gaps in knowledge and translation. We discuss these gaps and highlight innovative interventions that help address

them, focusing on cardiovascular disease and cancer. We also provide recommendations for advancing the field of

health equity and informing the implementation and evaluation of policies that target health disparities through

improved access to care and quality of care. FULL TEXT  

Headnote

ABSTRACT In the United States, racial/ethnic minority, rural, and low-income populations continue to experience

suboptimal access to and quality of health care despite decades of recognition of health disparities and policy

mandates to eliminate them. Many health care interventions that were designed to achieve health equity fall short

because of gaps in knowledge and translation. We discuss these gaps and highlight innovative interventions that

help address them, focusing on cardiovascular disease and cancer. We also provide recommendations for

advancing the field of health equity and informing the implementation and evaluation of policies that target health

disparities through improved access to care and quality of care.

The need to eliminate disparities in health and health care has long been recognized. Nonetheless, populations

such as racial/ethnic minority groups, rural residents, and adults with low incomes continue to experience

suboptimal access to and quality of health care.1-7 Disparities in health and health care are especially pronounced

in cardiovascular disease and cancer, which are the leading causes of death in the United States.1-7 In

cardiovascular disease, for instance, compared to non-Hispanic whites, African Americans and Hispanics have a

higher prevalence of hypertension and poorer blood pressure control, which contributes to greater morbidity and

mortality.1,3 Similarly, lowincome adults are more likely to have at least one cardiovascular disease risk factor,

compared to adults with higher incomes, and rural residents have poorer access to care and a greater burden of

risk factors, compared to nonrural residents.5,6 (For an additional discussion of racial/ethnic disparities in cancer

and cardiovascular disease in these populations, see online Appendix Exhibit 1.)8

Several interventions have been developed to address disparities in access to and quality of health care.4,9-12

However, there have been only modest improvements in reducing persistent disparities in cardiovascular disease

and cancer care at the national level.1,3,6 If effective interventions are to be designed, targeted, and implemented,

it is critical to understand the complex, multilevel factors that influence the presence of these disparities.

In this article we discuss important components of research and interventions to address health care disparities

that many existing efforts do not address. We also offer examples of programs developed by the Centers for

Population Health and Health Disparities-a network of research centers sponsored by the National Institutes of

Health-that do address many of these missing components. Using a model adapted from the work of Edwin Fisher

and colleagues,13 we contextualize multilevel influences on health disparities, their intervention targets, and the

key stakeholders and outcomes that are affected bythe interventions.Wealso provide key lessons, drawn from the

literature and from a qualitative survey of the Centers for Population Health and Health Disparities Access to Care

and Quality of Healthcare Services Consortium members, to inform future interventions and policies aimed at

disparities.

Interventions Targeting Disparities

Complex factors influence disparities in access to and quality of services.12,14-20 These include individual patient

factors (level 1); family, friends, and social support factors (level 2); provider and organizational factors (level 3);

and policy and community factors (level 4) (Exhibit 1).

As Electra Paskett and colleagues explore in this issue of Health Affairs, interventions that address factors at

multiple levels of the model may be more effective than those that target only one level.21 For example, an

intervention to reduce coronary heart disease disparities could include self-management training for patients with

low health literacy, a decision support tool for clinicians, and a partnership between a health care system and a

community-based organization to train community health workers to help patients address complex psychosocial

and financial barriers.

Critical Gaps In Knowledge And Translation

Many interventions have been developed in recent decades to address disparities in cardiovascular disease and

cancer care.4,9,12 While some of these interventions have been effective at reducing disparities for certain

underserved groups, they reflect important gaps in research and translation. Drawing on previous systematic

reviews4,9,12 and the work of the Access to Care and Quality of Healthcare Services Consortium, we highlight

fifteen critical knowledge and translation gaps (organized by the four levels in our model) that many health care

disparities interventions do not address (see Appendix Exhibit 2). We organize them by their target intervention

levels, which align with the four levels in our model (see Appendix Exhibit 2).8 Understanding these gaps could

guide the development of needed interventions and policies to achieve health equity.

ALL MODEL LEVELS Four critical gaps exist across all four levels of the model (Exhibit 1). There is a need for

interventions that incorporate the engagement of patients and of stakeholders more broadly in developing, testing,

and disseminating interventions. It is not known whether multilevel interventions are more effective than those

that target only single-level factors; research can test for this-for example, comparing an intervention that targets

patient education, provider communication skills, and health system staffing and an intervention that targets

patient education alone. In addition, there is a need to compare the effectiveness of universal approaches that

target all patients versus approaches that address specific barriers or target underserved populations; research

can test for this as well. Finally, disparities interventions and research must describe and address challenges to

program implementation and sustainability and to the translation of research into real-world practice.

SPECIFIC LEVELS At the levels of policy and community (level 4) and organization and provider (level 3), there is

one critical gap: Interventions should do more to enhance linkages between health care systems and the

communities they serve.

At level 3 (organization and provider) alone, there are five critical gaps. First is the need for interventions and

research to address, for a particular condition or set of conditions, the entire spectrum of health care-from

prevention and primary care to specialty care, hospitalization, and postdischarge treatment. Also at this level,

interventions with the following four aims are needed: to demonstrate whether and how teambased care can be

used to improve access to and coordination of care for underserved groups, to determine how to optimize the use

of data sources and health information technology, to improve health professionals' communication skills and

cultural competence (reducing the impact of biases against underserved groups), and to increase the focus of

health care organization leaders on equity as an essential element in quality improvement.

At level 2, family, friends, and social support, there is one critical gap: Efforts are needed to better address cultural

differences in family decision making and make use of social network dynamics in intervention approaches.

At level 1, individual patient, there are four critical gaps. More interventions are needed that are designed to reduce

disparities between groups and not just improve outcomes in a particular group; that include less well-studied

populations such as American Indians or Alaska Natives, rural residents, refugees, and immigrants; that improve

medication access, treatment adherence, and patient empowerment; and that measure the durability of

intervention effects over longer periods of time.

Addressing These Gaps and Advancing Health Equity

The Centers for Population Health and Health Disparities, established in 2003, have developed several

interventions to reduce disparities in access to and quality of services for cardiovascular disease and cancer.

These interventions address many of the critical knowledge and translation gaps we identified above.

REDUCING DISPARITIES IN CARDIOVASCULAR DISEASE CARE Five interventions addressed critical gaps in health

care research on cardiovascular disease.22-26 We summarize the key components of these interventions in

Appendix Exhibit 38 and highlight two of them below.

The Heart Healthy Lenoir Project25 was a health system-level intervention to reduce geographic and racial/ethnic

disparities in blood pressure control among patients of rural primary care practices in Lenoir County, North

Carolina. The intervention involved broad stakeholder engagement and a community-based participatory research

approach. It included the integration of a community health coach and home blood pressure monitoring training

for patients and on-site coaching or facilitation to help practices build their capacity to implement evidencebased

quality improvement methods. Practices were taught how to abstract and respond to racespecific data on blood

pressure control within electronic health records (EHRs), implement standardized hypertension visit protocols,

devise and use blood pressure medication algorithms to help patients with persistently uncontrolled hypertension

get their blood pressure under control, and engage all clinic staff members in health disparities education. The

intervention engaged and retained study participants, with greater retention of African Americans than whites and

with significant blood pressure reductions in both African Americans and whites.25

Project ReD CHiP (Reducing Disparities and Controlling Hypertension in Primary Care) was a pragmatic study

aimed at developing and testing the real-world effectiveness of a multimethod intervention to improve health

system quality within a nonrandomized trial.26 The intervention was grounded in implementation science and

engaged community and health system stakeholders in its design and execution. It targeted patients, providers,

clinical staff members, and the health care system to improve hypertension care and reduce racial disparities in

blood pressure control in a large clinical practice network in Maryland.

Project ReD CHiP implemented a new protocol, which is being sustained by the practices, to increase the

accuracyof blood pressuremeasure- ments taken by front-line clinical staff members. It also delivered care

management to patients by adding pharmacists and dietitians to primary care teams. Despite challenges with

reaching a high proportion of the target population, the care management program led to significantly greater

reductions in blood pressure in patients who completed all aspects of the program relative to those who did not

participate or did not complete all aspects. In addition, racial disparities in systolic blood pressure were no longer

present at the end of the study.27

Finally, the project introduced an audit and feedback process in which race-specific data on blood pressure control

from the EHR was used to generate a computer-based dashboard. Updated monthly, the dashboard was intended

to improve providers' awareness of disparities in hypertension control among their own patients and to inform

clinic-level quality improvement strategies to help providers attain national benchmarks and address hypertension

disparities.

REDUCING DISPARITIES IN CANCER CARE Five additional interventions addressed critical gaps in cancer health

care research.28-32 We summarize key components of these interventions in Appendix Exhibit 38 and highlight

two interventions below.

Fortaleza Latina, an intervention conducted in western Washington State, showed that a culturally tailored

intervention involving promotoras- community members who received specialized training to deliver health

education in the community-could improve rates of mammography screening among Latinas who received care at

federally qualified health centers.29 The intervention also showed that promotoras can successfully undertake

motivational interviewing. Fortaleza Latina was developed as a partnership among research institutions, a

communitybased primary care clinic organization, and a cancer treatment center.

Another intervention, Project CLIQ (Community Linked to Quit), integrated the following services into the primary

health care delivered to smokers: tobacco counseling and proactive outreach to patients, using interactive voice

response automated calls; motivational counseling from tobacco treatment specialists; free nicotine replacement

therapy; and access to community-based resources.32 Patients' EHRs were used to identify current smokers who

were black, white, or Hispanic and who lived in census tracts with low median household income, and to create a

database for outreach phone calls by the interactive voice response system. That system sent an automated e-

mail message to a tobacco treatment specialist when a patient requested contact. The intervention proved to be a

more effective strategy than usual care to improve smoking cessation among low-income and minority adults.32

Informing Future Interventions

In our qualitative survey of the Accesst°Care and Quality of Healthcare Services Consortium members, we also

identified a number of key lessons that could inform the development of future interventions to eliminate

disparities. Patients and families prefer a health care delivery approach that takes into account the whole person

over a disease-specific approach. Many patients and families also desire programs that connect them with

resources within their local communities, such as fresh food markets, smoking cessation classes, and free support

groups. Thus, programs that leverage existing community strengths and buildpartnerships between health

systems and community-based organizations will likely improve the acceptability, successful implementation, and

long-term effectiveness of interventions.

Engaging organizational leaders, front-line providers, and other staff members continuously in the planning,

design, and implementation of interventions is also important and enhances interventions' uptake, effectiveness,

and sustainabilty. Researchers and policy makers should seek funding and other resources to engage and

empower patient and community stakeholders in interventions, to improve the interventions' sustainability and

potential for dissemination. Funders typically do not provide this type of support or provide enough funding to

develop and sustain the necessary amount of engagement. Because support for promising interventions often

ends when research funding ends, new streams of funding are needed to adapt and sustain effective interventions.

Sponsorship from payers, health systems, public entities, and private-sector groups is vital to the translation of

effective interventions into practice and to the scaling up of these interventions across populations and settings.

We also learned that universal policies, such as health insurance reform in Massachusetts, are important but not

sufficient to eliminate disparities.33,34 When universal policies are combined with approaches that target at-risk

populations, however, results in the form of reduced disparities can be dramatic.

For instance, the Delaware Cancer Treatment Program,35 created in 2004 through legislation, provides universal

screening and treatment of colorectal cancer-including patient navigation for screening, as well as care

coordination and case management-for all residents of the state. The program also uses a targeted approach, by

providing insurance coverage for these services for uninsured and poor residents. The program has eliminated

disparities in screening and disease incidencerates, decreased the percentageof African Americans with regional

and distant disease from 79 percent to 40 percent, and nearly eliminated mortality disparities.35

The Affordable Care Act (ACA) has led to the most significant changes to the US health care system since

Medicare and Medicaid were created in 1965.36,37 Although focused primarily on improving the health of the

overall population, the law required that data collection standards be established for the categories of race,

ethnicity, sex, primary language, and disability status, and that these data be collected and reported in national

population health surveys. The law also required a report to Congress on approaches for collecting and evaluating

data on health care disparities in Medicaid and the Children's Health Insurance Program (CHIP).38 Other ACA

provisions present providers and health plans with opportunities to adopt and tailor effective disparities

interventions, target at-risk groups, and bring interventions to scale to advance health equity.

To inform future disparities interventions and policies, it will be necessary to conduct natural experiments on

health care reform and other state and national policies to monitor their impact on disparities over time, by

comparing states with different degrees of adoption to document the impact of these policies on the health

ofunderservedpopulations. Inaddition, demonstration projects are needed to identify ways to provide incentives for

targeted approaches at the provider or organization level and incorporate those approaches into performance

measures. Lastly, payment model reforms must be monitored for potential unintended consequences, such as

disenfranchising targeted populations or unfairly penalizing safety-net providers. The reforms should incorporate

strategies such as case-mix adjustment of performance metrics and adjusted payments for safety-net providers

who serve a more complex population without private insurance, compared to providers who serve privately

insured populations with better access to routine care.

Conclusion

There is still a great deal of work to be done to improve access to and quality of care to achieve health equity. Past

interventions designed to reduce health care disparities have had important shortcomings, but recent

interventions show promise in addressing fundamental knowledge and translation gaps. Practical and scalable

multilevel interventions, guided by transdisciplinary research collaborations and broad stakeholder engagement,

may be the most effective approach and lead to more sustainable community- and system-level changes than

single-target interventions that do not engage stakeholders from several sectors of society. Additionally, programs

that couple universal population-level strategies with targeted approaches for at-risk groups will add tremendous

value to current efforts to advance health care equity. Collaborations among researchers, providers, and policy

makers to overcome implementation challenges, monitor the effects of policies on underserved populations, and

advocate for funding are also critical to achieving health equity. ?

Sidebar

The authors thank the Centers for Population Health and Health Disparities Access to Care and Quality of

Healthcare Services Consortium members and funders. A complete list of consortium members and funders

appears in the Appendix (see Note 8 in text).

Footnote

NOTES

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2 Bradley CJ, Given CW, Roberts C. Race, socioeconomic status, and breast cancer treatment and survival. J Natl

Cancer Inst. 2002;94(7):490 - 6.

3 Centers for Disease Control and Prevention. Racial/ethnic disparities in the awareness, treatment, and control of

hypertension -United States, 2003-2010. MMWR Morb Mortal Wkly Rep. 2013;62(18): 351-5.

4 Clarke AR, Goddu AP, Nocon RS, Stock NW, Chyr LC, Akuoko JA, et al. Thirty years of disparities intervention

research: what are we doing to close racial and ethnic gaps in health care? Med Care. 2013;51(11):1020-6.

5 Crosby RA, Wendel ML, Vanderpool RC, Casey BR, editors. Rural populations and health: determinants,

disparities, and solutions. San Francisco (CA): Jossey-Bass; 2012.

6 National Center for Health Statistics. Health, United States, 2011: with special feature on socioeconomic status

and health [Internet]. Hyattsville (MD): NCHS; 2012 May [cited 2016 Jun 27]. Available from:

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7 Vargas Bustamante A, Chen J, Rodriguez HP, Rizzo JA, Ortega AN. Use of preventive care services among Latino

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8 To access the Appendix, click on the Appendix link in the box to the right of the article online.

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quality-of-care/downloads/4302brtc. pdf

AuthorAffiliation

Tanjala S. Purnell is an assistant professor in the Department of Surgery and training director of the Johns

Hopkins Center to Eliminate Cardiovascular Health Disparities, both at the Johns Hopkins University School of

Medicine, in Baltimore, Maryland.

Elizabeth A. Calhoun is a professor in the Department of Public Health Policy and Management at the University of

Arizona, in Tucson. At the time this research was conducted, she was codirector of the Center for Population

Health and Health Disparities at the University of Illinois at Chicago.

Sherita H. Golden is the Hugh P. McCormick Family Professor in the Department of Medicine at the Johns Hopkins

University School of Medicine and a core faculty member in the Johns Hopkins Center to Eliminate Cardiovascular

Health Disparities.

Jacqueline R. Halladay is an associate professor in the Department of Family Medicine and the Center to Reduce

Cardiovascular Disparities, School of Medicine, at the University of North Carolina at Chapel Hill.

Jessica L. Krok-Schoen is a research specialist in the Comprehensive Cancer Center and the Center for Population

Health and Health Disparities at the Ohio State University, in Columbus.

Bradley M. Appelhans is an associate professor in the Department of Preventive Medicine and the Center for Urban

Health Equity at Rush University, in Chicago.

Lisa A. Cooper (lisa.cooper@ jhmi.edu) is the James F. Fries Professor in the Department of Medicine and director

of the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, both at the Johns Hopkins University

School of Medicine.

DETAILS

Subject: Translation; Access; Equity; Implementation; Cancer; Rural areas; Minority groups;

Quality of health care; Health care services policy; Health care access; Rural

populations; Population; Socioeconomic factors; Health care policy; Intervention;

Health care; Cardiovascular diseases; Medicaid; Health disparities; Quality; Heart

diseases; Patient satisfaction; College professors; Minority &ethnic groups;

Cardiovascular disease; Public health; Consortia; Patient Protection &Affordable

Care Act 2010-US; Preventive medicine; Ethnic minorities; Patient education

Location: United States--US Massachusetts

Company / organization: Name: Johns Hopkins University School of Medicine; NAICS: 611310

LINKS Linking Service

Publication title: Health Affairs; Chevy Chase

Volume: 35

Issue: 8

Pages: 1410-1415

Number of pages: 6

Publication year: 2016

Publication date: Aug 2016

Section: ADDRESSING DISPARITIES

Publisher: The People to People Health Foundation, Inc., Project HOPE

Place of publication: Chevy Chase

Country of publication: United States, Chevy Chase

Publication subject: Insurance, Public Health And Safety

ISSN: 02782715

Source type: Scholarly Journals

Language of publication: English

Document type: Journal Article

Document feature: References

DOI: http://dx.doi.org/10.1377/hlthaff.2016.0158

ProQuest document ID: 1822087395

Document URL: http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocv

iew%2F1822087395%3Faccountid%3D27965

Copyright: Copyright The People to People Health Foundation, Inc., Project HOPE Aug 2016

Last updated: 2018-10-05

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