Major disparities exist along racial and ethnic lines in the United States for various medical conditions, but guidance is scarce about how to reduce these gaps. Now, a new "roadmap" has been unveiled to give organizations expert guidance on how to improve health equity in their own patient populations.
Finding Answers, a national program based at the University of Chicago and funded by the Robert Wood Johnson Foundation, seeks evidence-based solutions to reduce racial and ethnic health disparities. Its new roadmap, outlined as part of a symposium of six papers published today in the Journal of General Internal Medicine (JGIM), builds upon seven years of administering grants, reviewing literature, and providing technical assistance to reduce health disparities.
The roadmap's architects hope it can provide direction on creating effective and sustainable interventions as the health disparities field shifts from measuring the problem to taking action.
"Often when you say the challenge is to reduce disparities, people feel overwhelmed. It's a big challenge," said Marshall Chin, MD, director of Finding Answers and Richard Parrillo Family Professor of Medicine at the University of Chicago Medicine. "But the roadmap provides order so that people can avoid missing what's necessary to create the change."
The paper highlights the initial need for recognizing disparities and commitment to their reduction, and suggests that programs to reduce disparities should be integrated into broader quality improvement efforts at clinics, hospitals and other health systems.
"In the past, people did disparities work or quality work, but the two wouldn't touch one another," Chin said. "We're merging the quality improvement field and the disparities field."
The roadmap also contains advice on designing interventions to address disparities, drawing upon systemic reviews of disparities research in various diseases. Five such reviews — on HIV, colorectal cancer, cervical cancer, prostate cancer and asthma — accompany the roadmap article in the JGIM symposium. [Fact sheets for each review article are available on request.]
Researchers identified characteristics of successful interventions across the five new articles and previously published reviews of cardiovascular disease, diabetes, depression and breast cancer. Effective projects were found to utilize team approaches to care, patient navigation, cultural tailoring, collaboration with non-health care partners such as families or community members, and interactive skill-based training.
The reviews also identified potential targets for reducing health disparities that have yet to be examined. For example, in colorectal cancer, reviewers found that projects concentrated only on improving minority screening rates but did not include post-screening follow-up or adherence to treatment. Many interventions also exclusively targeted patient knowledge and behavior to reduce disparities, instead of looking at other components of the health care system.
"Most interventions have been focused on the patient, essentially asking the patient to change rather than looking at the people who are serving the patient and saying, 'What can we change with that system,'" said Amanda Clarke, MPH, project manager for Finding Answers and co-author of the roadmap paper. "There's opportunity to do more research and more interventions that are targeting the organization, the immediate care team, and how the team dynamics work."
While offering general guidelines for best practices, the authors point out that the specifics of any organization's effort to reduce disparities must be custom-fit to the patient population and community.
"What may work in one setting, may not work in another," said Scott Cook, PhD, deputy director of Finding Answers and a co-author on the paper. "We thought the roadmap would be a good idea because it would provide guidance and some sort of rail guards to keep people from going way off the path and losing track of addressing disparities in a way that will work."
The roadmap also emphasizes the need to continually evaluate whether a particular intervention is working, making adjustments as needed. Organizations - and policymakers - also should consider the financial sustainability of efforts to reduce disparities and be mindful of unintended consequences for disparities as health care reforms are implemented.
"You need to have the financial mechanisms in place to make these efforts sustainable," Chin said. "You can have a very motivated health care organization that knows what to do to reduce disparities, but if in the long run the organization can't afford to support that work, then it's going to be really hard for the work to be done. From a policy perspective, you need to put in place the incentives so people are able to do the right thing - what they want to do, and what they know will work to reduce disparities."