A Roadmap and Best Practices for Organizations to Reduce Racial and Ethnic Disparities in Health Care

Organizations can do more than report health disparities by integrating interventions to reduce disparities into their quality improvement processes.

Introduction

In this special symposium, the authors report findings from Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation. This project investigated and evaluated interventions to reduce racial and ethnic disparities in care, performed systematic reviews of disparity-reduction interventions in healthcare, and provided technical assistance to other healthcare organizations. 

The authors report findings from the systematic reviews on disparity-reduction interventions in healthcare and provide a roadmap for organizations to follow to reduce health disparities. The authors encourage healthcare organizations to go beyond simply reporting health disparities; these organizations should hold themselves responsible for reducing disparities. The authors highlight a predominant disparity-reducing intervention focus on collecting and reporting race-specific data and then creating an intervention based on that data. However, many interventions often dismiss essential steps to ensure interventions are sustainable long-term. This article provides a roadmap that offers six steps for healthcare organizations to implement and ensure balance across the design of their interventions. The roadmap’s findings are applicable to a variety of healthcare settings ranging from public, nonprofit, and private providers who manage care organizations and payors to health departments and academic medical centers. 

Marshall H. Chin, MD, MPH is the Richard Parrillo Family Distinguished Service Professor of Medicine at the University of Chicago School of Medicine. Amanda R. Clarke, MPH, is Director of Programs at California Health Care Safety Net Institute. Robert S. Nocon, MHS is an Assistant Professor in Health Systems Science at the Kaiser Permanente Bernard J. Tyson School of Medicine. Alicia A. Casey, MPH is a Research Associate at the Georgia Health Policy Center. Scott C. Cook, PhD is a Co-Director at Advancing Health Equity: Leading Care, Payment, and Systems Transformation at the University of Chicago. Anna P. Goddy, MSc and Nicole M. Keeseecker, MA, as well as all of the authors, were part of the Robert Wood Johnson Foundation Finding Answers: Disparities Research for Change National Program Office and the Center for Health and the Social Sciences at the University of Chicago.

Methods and Findings

The authors conducted a systematic review of disparity reduction interventions in five healthcare areas: asthma, HIV, colorectal cancer, prostate cancer, and cervical cancer. 

• From the asthma review, they found that educational interventions were most common.
• From HIV, they found that interactive, skills-based instruction was more likely to be effective than didactic educational approaches for changing sexual health behavior. 
• The colorectal cancer review highlighted key gaps as the review identified no articles that described interventions to reduce disparities in post-screening, follow-up treatment, survivorship, or end of life care. 
• The cervical cancer review identified how navigation can improve screening. 
• Lastly, prostate cancer review also focused on the importance of educational strategies to target screening as well as how cognitive behavioral strategies can impact quality of life. 

The authors point out that promising interventions frequently were:

•  Multifactorial and targeted multiple leverage points along a patient’s pathway of care.
•  Culturally tailored and employed a multi-disciplinary team of care providers.
•  Interactive and provided skills training rather than didactic approaches (especially for educational interventions). 

The authors also point to the potential of interventions reducing health disparities when the interventions focus on patient navigation, family participation, and community involvement. 

Ultimately, within the review, the authors found that a majority of interventions focused on  changing the knowledge and behavior of patients through  some form of education. Yet, there continues to be a lack of data and research on the efficacy of interventions targeting providers, microsystems, organizations, communities, and policies.

Conclusions

Based on the findings, the authors provide a six-step roadmap for organizations to consider reducing health disparities. These include:

1. Recognize disparities and commit to reducing them – to do so, it is key to stratify performance data by race, ethnicity, and language (REL) and provide training on specific populations and disparities for staff.
2.  Implement a basic quality improvement structure and process – create a culture of quality with a quality improvement team, processes, goals, and metrics. Utilize champions to help lead disparity reduction work and cultivate leadership support.
3. Make equity an integral component of quality improvement efforts – by recognizing equity as a cross-cutting dimension of quality and not marginalizing efforts to address disparities.
4. Design the interventions by first focusing on root causes of the disparities– consider the six levels of influence (patient, provider, microsystem, organization, community, and policy), learn from the literature and peers, use evidence-based strategies, and identify specific, tailored interventions. 
5. Implement, evaluate, and adjust the interventions – use implementation models, best practices, and evaluation strategies that lead to adjustments and improvements. 
6. Sustain the interventions – institutionalize the intervention and create financially sustainable models. These models can include providing incentives and reimbursements for team-based care, implementation of pay-per-performance programs for reducing racial and ethnic disparities or creating linkages between community and health care systems. 

Beyond reporting disparities, the authors concluded that organizations must design, implement, and sustain interventions that are focused and tailored to their specific populations, communities and environments. More importantly, however, they caution against paralysis from undertaking these efforts due to the need to be specific in these objectives. It is important that they begin by identifying actionable steps to address the disparities they identify and prioritize.