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ADDRESSING DISPARITIES By Tanjala S. Purnell, Elizabeth A. Calhoun, Sherita H. Golden, Jacqueline R. Halladay, DOI: 10.1377/hithaff.2016.0158 Jessica L. Krok-Schoen, Bradley M. Appelhans, and Lisa A. Cooper HEALTH AFFAIRS 35, NO. 8 (2016): 1410-1415 @2016 Project HOPE- The People-to-People Health Foundation, Inc. Achieving Health Equity: Closing The Gaps In Health Care Disparities, Interventions, And Research Tanjala S. Purnell is an assistant professor in the ABSTRACT In the United States, racial/ethnic minority, rural, and low- Department of Surgery and training director of the Johns income populations continue to experience suboptimal access to and Hopkins Center to Eliminate quality of health care despite decades of recognition of health disparities Cardiovascular Health Disparities, both at the Johns and policy mandates to eliminate them. Many health care interventions Hopkins University School of that were designed to achieve health equity fall short because of gaps in Medicine, in Baltimore Maryland. knowledge and translation. We discuss these gaps and highlight innovative interventions that help address them, focusing on Elizabeth A. Calhoun is a professor in the Department cardiovascular disease and cancer. We also provide recommendations for of Public Health Policy and advancing the field of health equity and informing the implementation Management at the University of Arizona, in Tucson. At the and evaluation of policies that target health disparities through improved time this research was conducted, she was codirector access to care and quality of care. Downloaded from http://content.healthaffairs.org/ by Health Affairs on January 29, 2017 by HW Team of the Center for Population Health and Health Disparities at the University of Illinois at Chicago. he need to eliminate disparities in address disparities in access to and quality of Sherita H. Golden is the Hugh P. Mccormick Family Professor in the Department of Medicine at the Johns T health and health care has long health care. However, there have been only been recognized. Nonetheless, modest improvements in reducing persistent populations such as racial/ethnic disparities in cardiovascular disease and cancer Hopkins University School of minority groups, rural residents, care at the national level. 13. If effective interven- Medicine and a core faculty and adults with low incomes continue to experi- member in the Johns Hopkins tions are to be designed, targeted, and imple- Center to Eliminate Cardio ence suboptimal access to and quality of health mented, it is critical to understand the complex, vascular Health Disparities. care.'-7 Disparities in health and health care are multilevel factors that influence the presence of especially pronounced in cardiovascular disease these disparities. Jacqueline R. Halladay is an associate professor in the and cancer, which are the leading causes of death In this article we discuss important compo- Department of Family in the United States.'- In cardiovascular disease, nents of research and interventions to address Medicine and the Center to for instance, compared to non-Hispanic whites, health care disparities that many existing efforts Reduce Cardiovascular African Americans and Hispanics have a higher do not address. We also offer examples of pro- Disparities, School of Medicine, at the University of prevalence of hypertension and poorer blood grams developed by the Centers for Population North Carolina at Chapel Hill. pressure control, which contributes to greater Health and Health Disparities-a network of re- morbidity and mortality. Similarly, low- search centers sponsored by the National Insti- Jessica L. Krok-Schoen is a income adults are more likely to have at least tutes of Health-that do address many of these research specialist in the Comprehensive Cancer Center one cardiovascular disease risk factor, compared missing components. Using a model adapted and the Center for Population to adults with higher incomes, and rural resi- from the work of Edwin Fisher and colleagues, 13 Health and Health Disparities dents have poorer access to care and a greater we contextualize multilevel influences on health at the Ohio State University, disparities, their intervention targets, and the in Columbus. burden of risk factors, compared to nonrural residents.56 (For an additional discussion of ra- key stakeholders and outcomes that are affected cial/ethnic disparities in cancer and cardiovas by the interventions. We also provide key lessons, cular disease in these populations, see online drawn from the literature and from a qualitative Appendix Exhibit 1.) 8 survey of the Centers for Population Health and Several interventions have been developed to Health Disparities Access to Care and Quality of 1410 HEALTH AFFAIRS AUGUST 2016 35:8Healthcare Services Consortium members, to in- Critical Gaps In Knowledge And form future interventions and policies aimed at Translation Bradley M. Appelhans is an disparities. Many interventions have been developed in re- associate professor in the cent decades to address disparities in cardiovas Department of Preventive Medicine and the Center for cular disease and cancer care.49,12 While some of Urban Health Equity at Rush Interventions Targeting Disparities these interventions have been effective at reduc- University, in Chicago. Complex factors influence disparities in access ing disparities for certain underserved groups, to and quality of services. 214-20 These include they reflect important gaps in research and Lisa A. Cooper (lisa.cooper@ jhmi.edu) is the James F. Fries individual patient factors (level 1); family, translation. Drawing on previous systematic re- Professor in the Department friends, and social support factors (level 2); pro- views*912 and the work of the Access to Care and of Medicine and director of vider and organizational factors (level 3); and Quality of Healthcare Services Consortium, we the Johns Hopkins Center to Eliminate Cardiovascular policy and community factors (level 4) (Ex- highlight fifteen critical knowledge and transla- Health Disparities, both at the hibit 1). tion gaps (organized by the four levels in our Johns Hopkins University As Electra Paskett and colleagues explore in model) that many health care disparities inter- School of Medicine. this issue of Health Affairs, interventions that ventions do not address (see Appendix Exhib- address factors at multiple levels of the model it 2). We organize them by their target interven- may be more effective than those that target only tion levels, which align with the four levels in our one level.21 For example, an intervention to re- model (see Appendix Exhibit 2).8 Understand- duce coronary heart disease disparities could ing these gaps could guide the development of include self-management training for patients needed interventions and policies to achieve with low health literacy, a decision support tool health equity. for clinicians, and a partnership between a ALL MODEL LEVELS Four critical gaps exist health care system and a community-based orga- across all four levels of the model (Exhibit 1). nization to train community health workers to There is a need for interventions that incorpo help patients address complex psychosocial and rate the engagement of patients and of stake- financial barriers. holders more broadly in developing, testing, and disseminating interventions. It is not known Downloaded from http://content.healthaffairs.org/ by Health Affairs on January 29, 2017 by HW Team EXHIBIT 1 Factors that influence disparities in access to care and quality of health care services, by level INTERVENTION TARGETS HEALTH CARE PROCESSES OUTCOMES LEVEL 4 Policy and Neighborhood and community community resources Organizational motivation, resources, staff attributes, KEY INTERACTIONS Clinical climate, and teamwork outcomes LEVEL 3 Organization and Patients and provider support networks Avoidable Patient programs and hospital services, insurance and admissions affordability, and provider- Health care Community and system-level supports providers health workers Patient Other experiences organizational of care LEVEL 2 members and Family, friends, Ongoing support from stakeholders Equity of and social support family and friends services Costs Patient education and LEVEL 1 clinical care; and biological, Individual sociodemographic, and patient psychological factors SOURCE Authors' analysis of findings from systematic reviews (see Notes 4, 9-12 in text). AUGUST 2016 35:8 HEALTH AFFAIRS 1411\fments taken by front-line clinical staff members. quested contact. The intervention proved to be It also delivered care management to patients by a more effective strategy than usual care to im- adding pharmacists and dietitians to primary prove smoking cessation among low-income and care teams. Despite challenges with reaching a minority adults. 32 high proportion of the target population, the care management program led to significantly greater reductions in blood pressure in patients Informing Future Interventions who completed all aspects of the program rela- In our qualitative survey of the Access to Care and tive to those who did not participate or did not Quality of Healthcare Services Consortium mem- complete all aspects. In addition, racial dispar- bers, we also identified a number of key lessons ities in systolic blood pressure were no longer that could inform the development of future in- present at the end of the study.27 terventions to eliminate disparities. Patients and Finally, the project introduced an audit and families prefer a health care delivery approach feedback process in which race-specific data that takes into account the whole person over a on blood pressure control from the EHR was disease-specific approach. Many patients and used to generate a computer-based dashboard. families also desire programs that connect them Updated monthly, the dashboard was intended with resources within their local communities, to improve providers' awareness of disparities in such as fresh food markets, smoking cessation hypertension control among their own patients classes, and free support groups. Thus, pro- and to inform clinic-level quality improvement grams that leverage existing community strategies to help providers attain national strengths and build partnerships between health benchmarks and address hypertension dis- systems and community-based organizations parities. will likely improve the acceptability, successful REDUCING DISPARITIES IN CANCER CARE Five implementation, and long-term effectiveness of additional interventions addressed critical gaps interventions. in cancer health care research. - We summa- Engaging organizational leaders, front-line rize key components of these interventions in providers, and other staff members continuously Appendix Exhibit 3 and highlight two interven- in the planning, design, and implementation of tions below. interventions is also important and enhances Fortaleza Latina, an intervention conducted in interventions' uptake, effectiveness, and sustain Downloaded from http://content.healthaffairs.org/ by Health Affairs on January 29, 2017 by HW Team western Washington State, showed that a cultur- nabilty. Researchers and policy makers should ally tailored intervention involving promotoras- seek funding and other resources to engage and community members who received specialized empower patient and community stakeholders training to deliver health education in the in interventions, to improve the interventions' community-could improve rates of mammogra sustainability and potential for dissemination. phy screening among Latinas who received care Funders typically do not provide this type of sup- at federally qualified health centers." The inter- port or provide enough funding to develop and vention also showed that promotoras can suc- sustain the necessary amount of engagement. cessfully undertake motivational interviewing. Because support for promising interventions of- Fortaleza Latina was developed as a partnership ten ends when research funding ends, new among research institutions, a community- streams of funding are needed to adapt and sus- based primary care clinic organization, and a tain effective interventions. Sponsorship from cancer treatment center. payers, health systems, public entities, and pri- Another intervention, Project CLIQ (Commu- vate-sector groups is vital to the translation of nity Linked to Quit), integrated the following effective interventions into practice and to the services into the primary health care delivered scaling up of these interventions across popula- to smokers: tobacco counseling and proactive tions and settings. outreach to patients, using interactive voice re- We also learned that universal policies, such as sponse automated calls; motivational counsel- health insurance reform in Massachusetts, are ing from tobacco treatment specialists; free important but not sufficient to eliminate dispar- nicotine replacement therapy; and access to ities. 33,34 When universal policies are combined community-based resources." Patients' EHRs with approaches that target at-risk populations, were used to identify current smokers who were however, results in the form of reduced dispar- black, white, or Hispanic and who lived in census ities can be dramatic. tracts with low median household income, and For instance, the Delaware Cancer Treatment to create a database for outreach phone calls by Program, created in 2004 through legislation, the interactive voice response system. That sys- provides universal screening and treatment of tem sent an automated e-mail message to a to- colorectal cancer-including patient navigation bacco treatment specialist when a patient re- for screening, as well as care coordination and AUGUST 2016 35:8 HEALTH AFFAIRS 1413