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10
DESIGNrNG A NATIONAL HEALTHCARE DISPARITIES REPORT
COMMITTEE REPORT
It is well established that race, ethnicity, socioeconomic status,
and geographic location are among the factors that influence health
care independent of patient need (IOM, 2002b; National Center for
Health Statistics, 2001; National Quality Forum, 2002; Nerenz et al.,
2002~. Growing concern over racial, ethnic, geographic, and other
disparities in health care prompted Congress in 1999 to require the
Agency for Healthcare Research and Quality (AH:RQ) to produce a
new annual report beginning in fiscal year 2003 (October I, 2002 to
September 30, 2003~. The National Healthcare Disparities Report
(NHDR) will take its place alongside another new annual report to
Congress to be called the National Healthcare Quality Report
(NHQR). Together, they will provide policy makers, consumers, and
others with a more complete picture of the health care that Americans
receive and of the areas that need attention.
To help it address a number of technical issues related to the
NHDR, AHRQ commissioned the Institute of Medicine (IOM) to
examine issues related to racial, ethnic, geographic, and
socioeconomic access to--and use of--health care services, as well as
to the quality of care provided. In addition, the TOM was asked to take
into account explanatory factors such as spoken language, literacy,
culture, community influences, and attitudes toward health. Also, the
~ As a federal agency AHRQ must use the racial categories specified by the
federal Office of Management and Budget (OMB) in OMB Directive 15:
American Indian or Alaska Native; Asian; Black or African American; Native
Hawaiian or other Pacific Islander; and White. OMB Directive 15 defines
ethnicity separately from race, and it is limited to Hispanic or Latino or Not
Hispanic or Latino. Currently, there is not a standardized treatment of racial
and ethnic subpopulations. See National Quality Forum (2002) for a
discussion of the lack of subpopulation definitions.
10
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11
IOM was asked to examine measures and data sources that could be
used in the report.2
AHRQ requested that the TOM consider issues related to the
NHDR within the context of the framework developed by the IOM's
Committee on the National Quality Report on Health Care Delivery in
its study, Envisioning the National Health Care Quality Report (IOM,
2001 c). The framework consists of a matrix of components of health
care quality and consumer perspectives on health care needs. The four
components of health care quality are based on those presented in
Crossing the Quality Chasm (TOM, 2001b): safety, effectiveness,
patient centeredness, and timeliness. There are four consumer
perspectives on health care needs: staying healthy, getting better,
living with illness or disability, and coping with the end of life.3
In the framework, equity is a component that applies to both
populations and individuals. It is defined in terms of"providing care
that does not vary in quality because of personal characteristics such as
gender, ethnicity, geographic location, and socioeconomic status"
(TOM, 200 Ib, p. 6~. For populations, equity means reducing disparities
in the use of health care services that are related to personal
characteristics such as race, ethnicity, socioeconomic background, and
geographic location. Research documents that insurance coverage is
particularly important to achieving this goal (IOM, 2001a; TOM,
2001b). For individuals, it refers to the receipt of safe and effective
services based on need. As Figure 1-1 shows, the framework treats
equity as a cross-cutting factor, applicable to each cell of the matrix.
AHRQ will use the same framework for the NHDR. This
reflects the agency's plan to make health care quality a major focus of
this report, which is appropriate since disparities often represent an
2 At the same time that the IOM Committee for Guidance in Designing a
National Health Care Disparities Report was meeting, the National Quality
Forum (NQF) was producing a report (National Quality Forum, 2002) that
addressed the issue of quality measures best suited to capturing health care
disparities. To avoid duplicating the work of the NQF, the committee focused
on matters relating to service utilization and access.
3 See chapter 2 of IOM (2001 c) for definitions of these terms and an
elaboration on the framework as a whole.
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12 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
"inequality in quality" (FiscelIa et al., 2000, p. 2579~. Within the
framework, the NHDR will highlight health care issues related to
equity and the extent to which health care disparities undermine its
achievement.
FIGURE 1-1 Framework for the National Healthcare Quality Report and the
National Healthcare Disparities Report
Components of Health Care Quality
Consumer ~ ~ _
Perspectives on =>
Heals Care Needs ~ ~ ~ ~ ~
Staying Healthy ~ _
Getting Better
Living with Illness or _
Disability _
Coping with the End _
cow
cow
an
.=
-
·E~
1
. ~
3
a
To carry out this work, the IOM established the Committee for
Guidance in Designing a National Health Care Disparities Report. The
committee met twice. At its initial meeting in January 2002, it planned
its work and discussed its charge. it also was briefed on disparities-
related issues by experts from AHRQ, the U.S. Bureau of the Census,
the National Center for Health Statistics (NCHS), the NQF, and the
TOM. The committee commissioned five consultants to address key
research topics. At the March meeting, they delivered presentations on
the following: Marian E. Gornick (independent consultant):
measurement of socioeconomic status in disparities research; Thomas
A. LaVeist (Johns Hopkins University): measurement of disparities in
health care services and quality; Nicole Lurie (RAND): measurement
of disparities in health care access; Thomas C. Ricketts, TII (University
of North Carolina-Chape} Hill): measurement of geographic units in
disparities research; and Ross Arnett (independent consultant):
subnational datasets for use in the NHDR. At the March meeting, the
committee also heard testimony from a number of other invited
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1: COMMITTEE REPORT
13
experts on health care disparities. These experts participated in one of
the following panels: Disparities in Public Health; Disparities in
Health Care Purchasing and Providing; Disparities in Health Care
Delivery; or General Comments on Disparities.4
1-1. MEASUREMENT OF SOCIOECONOMIC STATUS
IN DISPARITIES RESEARCH
Socioeconomic status is a complex concept that combines
dimensions of social and economic resources as well as societal
ranking or prestige. As such, it is related to social stratification, or "a
system of social relationships that determines who gets what, why"
(Kerbo, 1996, p. 11~; social class, or "social groups arising from
interdependent economic relationships among people" (Krieger et al.,
1997, pp. 344-5~; and other concepts identified with social inequality.
Socioeconomic status influences health care in a number of ways. For
example, an individuaT's or family's material circumstances affect
health care access, services, and quality since they are directly related
to adequate insurance coverage (TOM, 200 1a; Lurie, 2002~. Social
status affects health care by influencing the ways in which individuals
are perceived. For example, health care professionals are more likely
to take seriously those who appear to have higher status (Magnus and
Mick, 2000~. In addition, education, well-connected social networks,
experience in dealing with professionals, poise, and other aspects of
higher social position can help patients effectively navigate a complex
health care environment that features health care insurers and
individual and institutional providers, among others. The ability to
navigate this system can in turn influence the access, services, and
quality of care that patients receive (Gornick, 2002; TOM, 2002b;
Magnus and Mick, 2000~.
The NHDR should contain analyses of racial and ethnic health
care disparities that reflect the influence of socioeconomic status.
There are two main reasons for paying particular attention to
socioeconomic status. First, it would help to clarify the extent to which
health care disparities result from socioeconomic factors or from racial
4 See Appendix I for the Workshop Agenda and Appendix II for a summary
of the public testimony.
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1 4 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
and ethnic factors. Socioeconomic status is associated with race and
ethnicity: racial and ethnic minorities are more likely to have Tower
socioeconomic status as measured in a variety of ways, including
income, wealth, and education (National Research Council, 2001~.
Better understanding the relative effects that socioeconomic factors
and racial and ethnic factors have on disparities is critical to
identifying ways to eliminate them. Secondly, socioeconomic status
deserves attention in its own right because it has a pervasive influence
on both health status and health care. It is linked to health status in a
number of ways. For example, those with lower socioeconomic status
are more likely to lead socially isolated lives and to be unemployed or
to work at jobs that are unfulfi~ling and stressful (Marmot, 2002~. They
more frequently live in places where it is difficult to buy fresh food
and to exercise. Their environments are more apt to be polluted by
such elements as hazardous wastes, unclean air, and lead paint (IOM,
1999~. Socioeconomic status is also linked to differences in health
care. Those with Tower socioeconomic status are more commonly
uninsured and have more limited access to preventive, primary, and
specialized care. They are more likely to suffer adverse health
outcomes and poorer health status (IOM, 200 1a; TOM, 2002a).
1. The National Healthcare Disparities Report
should present analyses of racial and ethnic
disparities in health care in ways that take into
account the effects of socioeconomic status.
For the NHDR to adequately take into account the effects of
socioeconomic status, it should use socioeconomic status in two
different ways: first, as a stratification variable in collecting sample
data on racial and ethnic disparities in health care access, service
utilization, and quality; and secondly, as an independent vanable that
serves as a control in analysis. Stratification would ensure adequate
sample sizes of racial and ethnic populations with varying levels of
socioeconomic status. Further, controlling for socioeconomic status
would help to identify the extent to which disparities result from
factors associated with race and ethnicity and the extent to which they
result from factors associated with socioeconomic status. Using
socioeconomic status as both a stratif~er and control would be more
likely to yield reliable findings of the role that socioeconomic status
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1: COMMITTEE REPORT
15
plays in racial and ethnic health care disparities. Using socioeconomic
status only as a control variable assumes that a single model fits all
subgroups in the population. This assumption, however, may not be
valid. It may be, for example, that there is a significant positive
relationship between socioeconomic status and a particular dependent
variable among Blacks, but no significant relationship among Whites.
There might even be a significant negative relationship between the
variables among Asian Americans or American Indians. The NHDR,
therefore, should include analyses that stratify by race and ethnicity to
explicitly test whether the relationships among variables are the same
when each subgroup is considered in turn.
To understand the independent impact of socioeconomic status
on disparities, it is important to identify which of its dimensions have
greater effects on health care, facilitating the development of more
targeted and effective interventions. For example, are material
resources more strongly related to receipt of quality care than
educational level or occupation? If material resources are critical, then
efforts can be focused on formulating and implementing policies and
interventions to enhance economic well-being or to reduce the cost of
medical care. If occupation is strongly associated with receipt of
quality care, interventions can be focused on those in affected jobs. It
is also important to determine the extent to which disparities are rooted
in racial, ethnic, or socioeconomic issues. For example, is poor access
to specialized care more strongly related to race or to income?
Clarifying the impact of socioeconomic status on disparities would
enhance the accuracy of the NHDR as well as add to the mix of issues
that interventions need to address.
The complexity of socioeconomic status is more exactly
expressed in the many different ways that it has been operationalized
(Liberatos et al., 1988~. There does not appear to be a single right way
to operationaTize it. Different measures either taken by themselves or
together capture important aspects of socioeconomic status and how it
affects health care (Gornick, 2002; Liberatos et al., 1988~. There are
several major approaches to measuring socioeconomic status. They
include income, wealth, education, poverty level, occupation, and
deprivation indices, which are composite measures consisting of such
variables as employment status and access to a car. Some of the major
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1 6 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
approaches, namely income and education, are commonly used in the
research literature. Wealth, including property holdings and income
from investments, is less often used. Occupation is more frequently
applied in British studies of the relationship between socioeconomic
status and health status. Deprivation indices have not been extensively
used in studies of health care.
Each approach has advantages and disadvantages (Gornick,
2002~. At present, education and income are the measures of
socioeconomic status for which enough data are available for use in
the NH:DR. Education is a stable measure for adults, with nearly
complete reporting in surveys. Income is included in most publicly
reported datasets. Each has significant advantages, which have been
noted by Gornick (Gornick, 2002) and others (Krieger et al., 19971.
Survey respondents readily report information on their educational
backgrounds, and education is commonly regarded as a meaningful
and valid measure of socioeconomic status. Data on income are
relatively accessible to researchers.
It should also be noted that each has important disadvantages.
Education may have different social meanings across generations and
races and ethnicities. For example, a high school degree for the
postwar generation was associated with more economic opportunity
than a high school degree for younger generations. In addition,
minorities often attend schools with fewer resources and less prestige,
which can make their educational achievements less valued. Similarly,
an immigrant with a college degree from another country may not
receive the same economic returns as a person who graduated from an
American college. Income data are missing for a significant proportion
of people in most health care surveys. Survey respondents also tend to
underreport income. In addition, income more accurately captures the
financial resources available to minorities than to Whites, who are
more likely to own real estate and have other investments and assets
(Oliver and Shapiro, 2001; Smith, 2001~.
Is education or income the better measure of socioeconomic
status? Education and income are related variables: higher educational
levels are associated with higher income levels. But this does not
mean that they are interchangeable. For example, Gornick (Gornick,
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17
2002) examined the proportion of White and Black women over 65
who received mammograms, flu shots, and Pap smears in 1998 by two
levels of income (below and above $25,000) and two levels of
education (less than high school and high school or more). The data
reveal disparities by race whether socioeconomic status is measured in
terms of income or education. Nonetheless, stratification by income
and education yielded appreciably different numbers for analysis.
Almost nine times the number of Black women (985,000) had a lower
level of education than the number (111,000) who had a lower level of
income. More than two times the number of White women had a Tower
level of income (11,434,000) than education (5,472,000~. As this also
suggests, analyses of the relationship between socioeconomic status
and health care can vary depending on the quality indicator used and
the population or subpopulation examined.s
Which measure or measures of socioeconomic status should
AHRQ use in the NH:DR? This is an important question. To
adequately answer it will require a clearer understanding of the
relationship between socioeconomic status and health care. There is a
striking dearth of studies of the relationship of socioeconomic status to
health care. Income does appear to be a critical variable, and it is
related to insurance coverage. Those on the higher end often receive
private health insurance as a work-related benefit. While some on the
Tower end of the income distribution may qualify for Medicaid
depending on federal and state eligibility requirements, they are most
likely to lack it. Many of those in the middle also lack health insurance
(IOM, 2001a).
However, research does not show whether income mainly
accounts for the relationship of socioeconomic status to health care.
Nor does it indicate whether other variables with which income is
associated actually account for more of the relationship. For example,
research reveals that those at different income levels tend to use the
health care system in different ways. Those with higher incomes have
a greater tendency to use preventive services while those with lower
incomes have a greater tendency to use acute care sentences due in part
s It should also be noted that analyses can vary depending on the cutpoints
used for education, income, and other measures of socioeconomic status
(Liberatos et al., 19 8 8~.
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1 8 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
to greater morbidity. This pattern holds true even when cost is not a
factor, as is the case with the use of influenza vaccinations by
Medicare beneficiaries, a benefit that is completely covered by
Medicare (Gornick, 2000~. Is it income per se that accounts for these
different patterns? Or is it factors with which income is associated,
such as access to transportation and proximity to health care
providers?
2. AHRQ should pursue a research initiative to
more accurately and meaningfully measure
socioeconomic status as it relates to health care
access, service utilization, and quality.
AHRQ should sponsor research on the relationship of
socioeconomic status to health care. Exploration of the relationship
between socioeconomic status, health care, and other factors such as
race and ethnicity would help to identify the most appropriate
measures of socioeconomic status to use in studies on health care
disparities. Appropriate measures in turn would help to indicate which
of the many dimensions of socioeconomic status are most likely to
affect a particular aspect of health care and therefore to be associated
with outcomes.
The following are examples of important areas where more
research is needed:
· In general, which dimensions of socioeconomic status most affect
health care and why? How strongly are different measures of
socioeconomic status such as income, education, and occupational
prestige associated with health care?
· Should socioeconomic status be studied at the individual,
household, or community level? Research indicates that different
races, ethnicities, and nativities call for different levels of analysis.
For example, community-level measures may better capture the
social and economic status and environments of immigrants and
some races and ethnicities while individual- and household-level
measures may be more appropriate for others (Krieger et al.,
1997~.
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19
The status dimension of socioeconomic status is particularly
understudied, both in terms of how it does and does not empower
patients and how it affects the relationship that patients have to
providers and other aspects of the health care system. How might
status be operationalized? Is income sufficient? Or are other
measures of status, such as car and home ownership, needed?
· Is one measure of socioeconomic status adequate? Or do
composite measures, such as deprivation indices, perform better?
Are different dimensions of socioeconomic status implicated in
preventive, acute, or other aspects of health care? For example, is
it the case that attitudes toward health, health literacy, cost and
availability of transportation, or work schedule flexibility
influence a patient's use of preventive services, while income
more strongly accounts for use of acute care?
· The NHDR will be focused on issues of access to and within the
health care system, health care service utilization, and health care
quality. How are patterns in each related to a patient's
socioeconomic status? Are the results of quality measurement
affected by the socioeconomic status of the population more likely
to use particular services?
1-2. MEASUREMENT OF DISPARITIES IN ACCESS
TO AND WITHIN
THE HEALTH CARE SYSTEM
Access can be defined as entry to the system of care as well as
entry within the system of care. Access is a central aspect of quality,
and the NHDR should give it prominent attention. The framework of
the NHQR treats access as an important aspect of all four components
of health care quality: safety, effectiveness, patient centeredness, and
timeliness. However, access deserves greater prominence in its own
right because it is a critical starting point for quality care. As such, it is
a fundamental aspect of quality, especially for racial and ethnic
minorities, those with fewer socioeconomic resources, and those in
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20 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
disadvantaged geographic areas (TOM, 200 1a; TOM, 2002a; TOM,
2002b; National Center for Health Statistics, 2001~.
3. Access is a central aspect of health care quality.
As such, the National Healthcare Disparities
Report should give it prominent attention.
Access should be reconceptualized as a dimension of health
care rather than as a dimension of medical care alone. Access to
physicians and other medical care professionals is essential: it provides
the diagnoses, medical interventions, and monitoring that can be
critical to preventing and treating illness. However, primary care
physicians typically coordinate care received from other health care
specialists including nutritionists, dentists, and occupational, physical,
and mental health therapists.
Disparities in access depend in part on the social and human
capital of the patient and the community. Some factors play important
roles, including adequate and secure material resources; community
norms that favor healthy lifestyles; social support networks supplied
by families, mends, and religious, professional, social, and civic
organizations; the availability of safe and convenient places to exercise
and shop for fresh food; well-developed transportation systems; high
literacy rates; and Tow crime rates (Aday, 2001; Fiscelia, 2002; TOM,
2002b; Lurie, 2002; Ricketts, 2002~.
As such, a wide range of measures of access influence entry to
the system of care as well as entry within the system of care. They
include factors as diverse as the extent of insurance coverage,
language access services, and other aspects of culturally competent
care. For example, cultural competency is critical in the diagnosis and
treatment of mental illness: behavior that is interpreted as mental
illness in one culture may be an appropriate way of displaying emotion
in another culture (DHHS, 1999~.
The following are some of the new measures of access
suggested by Lurie for development and use in the NHDR:
Adequacy of insurance coverage. Based on work by Bashshur et
al. (Bashshur et al., 1993), Lurie defines underinsurance as "a
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34 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
al., ~ 998; Heymann, 2000; Lannon et al., 1995; Perioff et al., 1997~.
Complying with providers' instructions can be more difficult when
literacy is a problem or when health insurance is lacking or does not
fully cover the recommended treatment.
Should the NHDR only devote attention to matters under the
direct influence of the health care system? As defined by the
Committee on the National Quality Report on Health Care Delivery,
these matters refer to "care that can be influenced by the health care
system as it exists or as it is envisioned" (TOM, 200Ic, p. 84~. To
elaborates those in rural areas are more likelier to die from car accidents
(Ricketts, 2002~. Although the health care system can seek to improve
trauma care, many policy responses such as speed limits, road design,
and car design fall outside of its purview. The NHDR should mainly,
but not exclusively, address issues that the health care system could
directly affect. It is appropriate for AHRQ to make health care quality
and the quaTity-related performance of the health care system an
important focus of the NHDR as well. However, disparities are
inextricably related to issues that fall outside of the primary influence
of the system such as the availability of public and private
transportation (IOM, 2001a; TOM, 2002a; TOM, 2002b; Lurie, 2002~.
Therefore the NHDR should address these disparities too. For
example, the report could include data on disparities in reliance on
public transportation, which can make timely treatment difficult for
those in rural and inner city communities.
The NHDR will change and improve over time. For practical
reasons, it is likely that in the short term AHRQ would make use of
current measures and data sources on racial, ethnic, socioeconomic,
and geographic disparities in the early editions of the report. However,
with time and adequate resources, AHRQ will have the opportunity to
introduce more specific measures for use in later editions that will
more accurately detect the magnitude of health care disparities.
Measures could be drawn from those used in the NHQR that are
particularly relevant to racial, ethnic, socioeconomic, and geographic
disparities. These include measures of areas with unusually large
disparities; those likely to result in death or serious illness; or those
susceptible to improvement. Because of space limitations, AHRQ will
monitor a larger set of measures than it can include in the NHQR.
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35
Measures in this larger set could be used in the NHDR if they are more
pertinent to disparities. Also, measures of disparities in health care
service utilization and quality described by LaVeist (LaVeist, 2002)
and measures of disparities in access described by Lurie (Lurie, 2002)
could be used in the NHDR.
Lastly, the design and dissemination of the NHDR will be
critical to the report's success. A design that does not appeal to the
report's audiences wall discourage them from reading it, using it as a
reference source, and recommending it to others. Poor dissemination
will mean that fewer people will leam about it, with the result that its
annual updates on health care disparities will not have the impact that
they should. The design and dissemination strategies for the NHQR
developed by the Committee on the National Quality Report on Health
Care Delivery (IOM, 2001 c) are sound approaches that could in
general be applied to the NHDR as well.
1-7. CONCLUSION
It is important to accurately identify the disparities that are
primarily racial and ethnic and those that are primarily socioeconomic.
Therefore, the NHDR should present findings on racial and ethnic
health care disparities that reflect the impact of socioeconomic status.
Also, there is currently an inadequate understanding of the relationship
of socioeconomic status to health care. AHRQ should initiate research
on the relationship with the goal of producing more useful, accurate,
and meaningful measures of socioeconomic status.
The NHDR should include measures of high utilization of
certain health care services, such as greater minority use of emergency
department care, that may indicate poor access to care or quality of
care. To increase interest in the report by policy makers, consumers,
and other key audiences, the NHDR should present data on disparities
by state and by urban and by rural areas. Also, if the NHDR draws
from subnational data sources in the Tong term, AHRQ should
collaborate with data source sponsors to identify core elements in
these surveys that can be standardized.
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36 CUID~CE fOR THE NAT~AL HEALTH CAM DISPARITIES UPON
ARM has He oppo~i~ to maw Tic ~DR ~ valu~lc Ed
c~cOvc tool far cbminshng racist chick socioccono~c, Ed
gco~bic disp~bcs in Tic nabon~s basalt chic system. lo tsar
adv~tapc of ~k opposing ~RQ should reccivc adequ~c Rang
Ed rcso~ccs to develop Tic dstascts Ed mess~cs ~~ Fig be needed
far Tic repod.
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1: COMMITTEE REPORT
37
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Representative terms from entire chapter:
care disparities
