Cover Story
Disparity in care? Not in my hospital! Providers confront an uncomfortable reality.
The evidence is overwhelming: members of racial and ethnic minorities do not receive the same quality of health care as whites, even when they have the same coverage. That fact was underscored last year by an Institute of Medicine panel, which reviewed hundreds of clinical studies. For well-meaning hospital administrators, who considered equitable care in their organizations a given, the reports are a revelation. Now, pinpointing why those discrepancies occur and resolving them is a priority.
Jon Schandler, CEO at White Plains (N.Y.) Hospital, says that until recently, he would have denied the issue existed there. " 'No, that's not happening, because we treat everyone who walks in the door, so how could there be a care disparity?' " he says. "But the more I learned, the more I saw that if we can't communicate with people, if we don't understand what makes them tick, then there has to be a difference." Communication became an issue as the population of Latinos grew from 8 percent to 26 percent in White Plains over the last 10 years.
One thing Schandler has learned: Latinos are not a homogeneous group, but more than 20 groups of people with different cultures, religions and dialects. "Each one poses a challenge for us, making sure we deliver the same standard of care to everybody." For the White Plains facility, part of the solution is to employ more Latinos. The hospital is funding community college scholarships for nurses, radiology techs and others. After three years, it has 17 employees from the program.
Schandler also initiated language and cultural sensitivity training for all 13,000 hospital employees and hired a local Latino politician to help build bridges to Latino advocacy groups. The reaction was a pleasant surprise. "Instead of saying 'What took you so long?' the Latino community has been very embracing," Schandler says. (For more examples of how hospitals work on this issue, see sidebars.)
Schandler knows his efforts won't be a quick fix. Completing the cultural training for staff will take months. But his resolve is solid. "Our goal should be to have the same standard of care for everyone who walks in the door. We just have to figure out the tactics and strategies to get there."
Toward that end, the American Hospital Association is working to educate the field on this issue. It has convened a group of leaders to assess the most effective means for community-level action to eliminate disparities. "We hope to continue to add people--both in and outside the hospital field--as we identify those who can be good resources," says Carmela Coyle, senior vice president for policy at the AHA. The panel will meet for the second time in August.
The association is creating a clearinghouse of research, data and examples of how hospitals have addressed disparities. "We want to find ways of creating or using existing data sources, so that hospitals and communities can identify disparities and take steps to eliminate them," Coyle says.
To tackle the problem, hospitals need data about whom they treat and to connect it to the kind of care patients receive. While hospitals are experienced at collecting clinical information, most lack a track record with racial data. "For hospitals, this is relatively new," says Denise Love, executive director of the National Association of Health Data Organizations, Salt Lake City. "How are hospitals collecting it--asking individuals or through observation?" More states collect the race data from hospitals than use it, she says, because states doubt the quality of the data and are sensitive about the issue.
The fact that hospitals ask about race differently was underscored in a recent survey by the Health Research and Educational Trust, an AHA affiliate. Of 272 respondents, 79 percent reported that they do collect the data, but not all used the same categories. While 95 percent use a Caucasian/white category, only 81 percent use a Spanish/Hispanic/Latino category. "We need the data collection to be consistent to study this problem," says Romana Hasnain Wynia, principal investigator for an ambitious HRET project that seeks to make data comparable across health care while allowing hospitals to create the race categories that make sense for their own markets.
It is legal to collect the information. "Hospitals may worry that asking questions about race or ethnicity could be construed as a way to discriminate, but that's not the case," Wynia says. The project, called "Eliminating Disparities through Community and Hospital Partnerships," will involve six health systems that want to create a reliable method for collecting inpatient race and ethnicity data, then connect clinical procedures and outcomes with the race data to measure disparities at their institutions. They hope this will tell them where care delivery breaks down, and help them design interventions.
Parkland Memorial Hospital is among the six, and many of its patients are minorities--exactly the ones who would be hurt by these disparities. "If anyone should get involved, we should," says CEO Ron Anderson, M.D.
But there's a less altruistic reason to fix the problem: saving money. Removing disparities will help the bottom line, Anderson says. Minorities often access the system through the emergency department and enter the system when their conditions are severe. "We believe in preventive care," he says. "If we can get to minorities sooner, we will actually save money."
As the minority population increases, hospitals will have to better meet their needs. In Anderson's scenario, minority patient satisfaction would improve, and a health care institution would become more viable because it improves the experience--and outcomes--for these patients.
Carolyn Clancy, M.D., director of the Agency for Healthcare Research and Quality, agrees. "Let's face it--working on disparities is self-interest," she says. "The nation is changing and this is who hospitals and physicians will be serving." Her agency aims to help hospitals by providing information. In September, AHRQ will issue the first National Healthcare Disparities Report which will pull data from a number of sources, such as the Centers for Disease Control and Prevention, Medicare and AHRQ's own Healthcare Cost and Utilization Project to give "a national snapshot" of how various groups, including minorities, are faring with outcomes and care experiences.
"This issue is overwhelming and exciting to me," Clancy says. The evidence is overwhelming that the disparities occur, she says. "But it's exciting that a number of health care systems are now taking the problem very seriously."
Percent of patients who believe they would recieve better care if they were of a different race or ethnicity
| White | 1% |
| Black | 15% |
| Latino | 13% |
| Asian | 11% |
Percentage of minorities by region
| Midwest | 18.6% |
| South | 34.2% |
| Northeast | 26.6% |
| West | 41.6% |
Percentage of minorities by age group
| Under 25 | 38.9% |
| 25-44 | 32.8% |
| 45-64 | 23.5% |
| 65+ | 16.4% |
Percent of minorities reporting difficulty in communicating with physicians
| White | 16% |
| Black | 23% |
| Latino | 33% |
| Asian | 27% |
Disparities in care: Medicare managed care members, 2001
| White | Black | ||
| Breast cancer screening | 70.9% | 62.9% | Disparity 7.9% |
| Diabetic eye exams | 50.4% | 43.6% | Disparity 6.8% |
| Mental illness follow-up | 54.0% | 33.2% | Disparity 20.7% |
Minority Report
Three hospitals tailor programs to reach specific racial, ethnic groups
Providing the same care to all does not necessarily make the quality of care equitable. Patients' ethnic background often affects the health care they need and how it should be delivered to be most effective. Many hospitals, including the three profiled here, are now actively reaching out to various groups in their markets, becoming more educated to minority needs and, in the process, improving the health and well-being of those patients. These case studies are included in a report prepared for the American Hospital Association by Emily Friedman, a contributing writer to Hospitals & Health Networks.
Kimberlydawn Wisdom, M.D., now surgeon general of Michigan, was a senior staff physician and researcher in the Department of Emergency Medicine at Henry Ford Health System, Detroit. For too long, she had watched African-American men come into the emergency department with severe illness, often the result of diabetes. She often found that even if they knew they had the disease, they were unaware of how to manage it. One of her patients told an interviewer, "We'll be macho and half dead before we do something about it. If there are 10 men in a room and you ask the black ones about what kind of health issues they have, 90 percent of them will say, 'Ask my doctor; he knows.' The white men will know what's wrong with them."
Wisdom, in researching the situation, found that African-American male diabetics usually present for care later in the course of the disease. Their diabetes is also often complicated by hypertension, which is, unfortunately, commonplace among these patients. Furthermore, she says, these men often may be unwilling to admit that they are ill because it implies weakness.
In 1999, supported by grants from her organization and other sources, Wisdom launched the African-American Initiative for Male Health Improvement. Using a mobile van and visiting places in southeastern Michigan where health care access is compromised, she and her colleagues offer screening for and education about diabetes, cholesterol, hypertension and eye conditions. They go to locations ranging from community centers to barbershops. The van visits 60 sites a year.
There is also now an AIMHI clinic in Detroit. It accepts men, women and children; Wisdom says that 50 percent of the clinic's patients are women who have accompanied men to the center. In the past three years, AIMHI has been able to screen more than 7,000 people; at least a third tested positive for either diabetes or hypertension.
Wisdom explains, "For the African-American man to reach healthy middle age, he must overcome three major obstacles: infant mortality, adolescent crises and premature death as a result of chronic disease. We are hoping that through our work, we can see to it that those men who have overcome the first two obstacles can do the same with the third."
Henry Ford Health System recently launch the Institute on Multicultural Health, which has four goals:
Mariam Dahir lived in Somalia until the brutal civil war there. She sometimes worked as a translator for United Nations forces, but they could not protect her family; her 10-year-old son was killed. She came to Columbus, Ohio, and found work in the housekeeping department at Mount Carmel West Hospital. About four years ago, a clinical manager for the health system's outreach programs asked Dahir if she knew about a large and growing population of Somali refugees living near the hospital. Not only did she know of them, she knew many of them personally. The housekeeping supervisor agreed to "lend" Dahir to the outreach program to provide translation and the refugee became a caseworker--and an aspiring nurse.
"We owe her a huge debt of gratitude," says Sister Barbara Hahl, the health system's senior vice president for mission. Somalis began to settle in Columbus only a few years ago; today, they number at least 20,000, living in concentrated communities within the city. Although the city has welcomed them with other services, their health care needs were not being sufficiently met.
The Mount Carmel outreach van, which provides immunizations and primary care, began to visit three Somali communities and a welcoming center, and provides home visits to new Somali mothers who have given birth at a Mount Carmel facility. Outreach workers also discuss other needs with their clients, and provide help with everything from English-language education programs to cold-weather clothing.
Dahir's work is focused on a Somali community in an apartment complex near Mount Carmel West Hospital. She and her colleagues bring the outreach van, or go door to door, checking on the health of residents and asking if the children are immunized. Many clients are war refugees and carry scars--physical and emotional. Half the women are raising children without their fathers, who died in the war, are trapped in refugee camps in Africa or have simply disappeared.
Despite these horrors, they trust the outreach workers and nurses. They stand in long lines waiting for a visit with a nurse, and patients have been known to return to thank their caregivers, sometimes in newly learned English. According to Joy Parker, Mount Carmel's director of outreach services, this community is "an isolated place. Most people in Columbus don't even know these apartments exist. Thank God the hospital makes it possible for us to come here."
Just part of our job, says Hahl: "This is what we do in all our hospitals for people in any circumstances. We have an open-door policy; we turn no one away. So this was a natural place for us to go. It is part of our mission, our philosophy and our history."
Punxsutawney Area Hospital is a 50-bed rural facility whose service area includes more than 3,000 Amish residents. The Amish are a conservative branch of the Mennonite Church who do not use electricity or automobiles and reject most modern technologies and many contemporary practices. They live in insular communities, use horses and buggies for transportation, work mostly in agriculture, and have large families. Unfortunately, they are also at higher risk of hemophilia, dwarfism, measles, PKU, tuberculosis and glutaric aciduria than is the general population.
In 1995, the staff of Punxsutawney Area Hospital, after meeting with Amish leaders and residents, concluded that "not only did the hospital not understand the Amish people, but we were not meeting their needs for services," according to Ben Hughes, director of professional and corporate services for the hospital. Problems ranged from the difficulty for hemophiliac patients of getting to the hospital using horses and buggies to a serious measles outbreak. Hospital CEO Dan Blough launched the Amish Initiative, "a simple plan for a simple people."
Working with Amish leaders, the hospital staff conducted a needs assessment (which was difficult, given the closed nature of the community), identified barriers to care and went to work. All hospital employees were (and are) educated in Amish cultural and health care issues. Although many Amish are eligible for Hill-Burton funds for their care, they refused to apply for them because their faith does not acknowledge government programs. In 1996, the hospital petitioned the Department of Health and Human Services for a waiver for Amish patients, which was granted. Given that they wish to pay for their care, the waiver allows the Amish a heavily discounted price.
In 1999, the hospital established a primary care clinic in the middle of the Amish settlements. Because Amish women insist on being treated by a female physician, the hospital recruited a husband-and-wife physician couple to Marion County. The physicians have a working farm, which makes them welcome in this agricultural area. The program is funded entirely by the hospital and costs $900,000 a year.
As a result of the Amish Initiative, the measles epidemic is over. Hemophiliac patients are often able to receive treatment in their homes from visiting nurses. Emergency department visits are down and primary care visits and screenings are up.
Ben Hughes says, "We believe that embracing diversity is part of our mission. We do not have qualifying statements about that mission. To solve the myriad problems associated with providing care to the Amish population, we had to first rethink our views and embrace philosophies of care that may be different from our own. In doing this, we were positioned to realize success."
Emily Friedman is an independant health policy and ethics analyst and a contributing writer to Hospitals & Health Networks.
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This article 1st appeared in the August 2003 issue of HHN Magazine.
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