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US Health Care Quality Varies
That was the message Carolyn Clancy, M.D., director of the national Agency for Healthcare Research and Quality (AHRQ), brought to Grand Rapids Monday at the first DeVos Medical Ethics Colloquy.
There are disparities related to race, ethnicity and socioeconomic status in the American health-care system and big gaps in quality of care, Clancy told a group of about 85 people gathered for the event at Grand Valley State University’s Cook-DeVos Center for Health Sciences.
AHRQ’s 2004 National Healthcare Disparities Report and 2004 National Healthcare Quality Report measure the quality of and disparities in four key areas of health-care: effectiveness, patient safety, timeliness and patient centeredness.
The agency tracks prevailing disparities in health-care delivery as it relates to racial and socioeconomic factors in “priority populations” and also looks at the quality of and differences in access to clinical services. The disparities report focuses on the equity dimensions of the health-care system, while the quality report focuses on the variations in health-care quality across the country, Clancy explained.
“The findings confirm what we’ve seen in many other studies — that African-American patients are less likely to receive evidence-based treatment than their white counterparts,” Clancy said. Evidence-based treatment is defined as “the conscientious, explicit and judicious use of current best evidence” in making decisions about the care of individual patients.
“We see this time and again when we have demographic information on patients: In overall quality of care there is a huge gap between the best quality care and the care that most people get. That gap is larger still for people who are members of racial or ethnic minorities and people who are poor.”
Blacks, for instance, received poorer quality care than whites for about two-thirds of quality measures and had “worse access” to care than whites for about 40 percent of access measures. Hispanics received lower qualtiy care than non-Hispanic whites for half of qualtiy measures and had worse access to care than non-Hispanic whites for about 90 percent of access measures.
Why all the focus on measurements?
The first reason is cost, Clancy said, noting that health-care costs have risen 50 percent over the past five years.
“Any of you that have had the opportunity to sit in a room with private employers, they’re looking to a day in the not-so-distant future when the young worker’s health insurance premium may be more than his salary, and they don’t think the current situation is sustainable.”
Some 45 million Americans don’t have any health insurance at all, so the nation’s health care delivery system is pretty stressed, she said.
“The lack of insurance is a huge, huge issue. Overall, Latinos seem the most likely to have no health insurance, which is something I think will be a bigger and bigger issue as this Congress and the states try to figure out what to do about this problem.”
The most recent disparity report did find improvements in health care provided to the nation’s poor, uninsured and minorities through federally supported health centers that minister to vulnerable populations. Although quality remains “variable” across the country, improvements also were seen in many areas at the state level, according to the report.
“The reports are important because we believe they can summarize information at a very high level for all of us and make it clear where improvement is most needed,” Clancy remarked.
Clancy acknowledged that quality is improving modestly in a number of areas, but at a very slow pace. Compared to the 2003 reports, nearly twice as many measures had improved than had deteriorated, she pointed out. The greatest percentage improvement was in nursing home care.
“There has been a sharp decline in the percentage of nursing home patients with moderate to severe pain, and I do believe that’s a premier example of the response to the requirement that nursing homes report publicly on their performance.”
The quality of care varies based on income, race, ethnicity and education level. It appears that the higher the income, the less difficulty a person has gaining access to a medical specialist. People who have some college education, too, are “significantly and strikingly more likely” to receive better quality care, regardless of race or ethinicity, Clancy said.
“Major opportunities for improvement still exist,” Clancy said. “We have a lot of work to do collectively. We can learn from the states and communities that are doing well.”
Clancy turned the discussion over to a panel of local experts that included: Fr. Mark-David Janus, director of the Catholic Information Center; Albert Lewis, Ph.D., director of the Aquinas Emeritus College; James Resau, Ph.D., Van Andel Research Institute senior program investigator and deputy to the director for programs; Jorgelina De Sanctis, M.D., resident physician, Grand Rapids Medical Education & Research Center (MERC); and Phyllis Gendler, dean of Grand Valley State University’s Kirkhof College of Nursing.
Gendler said part of the solution is educating people on how to access and navigate the health-care system. She also sees a lack of diversity in the nation’s nursing pool as a “big problem” today.
De Sanctis added that if medical staff is not diverse “a lot can get lost in translation.” As she sees it, lack of diversity among staff creates not only a language barrier but a cultural barrier that can lead to misinterpretation and misunderstanding.