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Opportunity at the Intersection of Quality Improvement, Disparities Reduction, and Health Literacy

George Isham, M.D., M.S.

HealthPartners


It is imperative for health care systems to understand that reducing health disparities and addressing health literacy are important strategies for improving health care system quality. Before exploring the integration of these three concepts, it is worthwhile to explore each component separately. More specifically, Isham spoke about the following issues:

  • The state of quality improvement research, variations in quality of care, and the rate of improvement in the United States;

  • Health disparities in the United States, progress in addressing health disparities, and health care system strategies to address disparities;

  • Health literacy and “the perfect storm” of declining literacy levels, an increasingly diverse population, and a large level of expected job growth in knowledge-intensive work environments; and

  • Ideas for improving disparities in health care and health literacy, including the use of a medical home model, changes in the structure of the care delivery system, and using evidence-based medical practices.



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2 Opportunity at the Intersection of Quality Improvement, Disparities Reduction, and Health Literacy George Isham, M.D., M.S. HealthPartners It is imperative for health care systems to understand that reduc- ing health disparities and addressing health literacy are important strategies for improving health care system quality. Before exploring the integration of these three concepts, it is worthwhile to explore each component separately. More specifically, Isham spoke about the following issues: • The state of quality improvement research, variations in quality of care, and the rate of improvement in the United States; • Health disparities in the United States, progress in address- ing health disparities, and health care system strategies to address disparities; • Health literacy and “the perfect storm” of declining literacy levels, an increasingly diverse population, and a large level of expected job growth in knowledge-intensive work environ- ments; and • Ideas for improving disparities in health care and health lit- eracy, including the use of a medical home model, changes in the structure of the care delivery system, and using evidence- based medical practices. 

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 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS QUALITY The United States has the most expensive health care system in the world. In spite of that, health care is of inconsistent quality and leads to poorer health outcomes relative to other, similar nations; for example, the United States has much higher infant mortality rates.1 There are many types of quality problems. There is overuse, underuse, and misuse of care. For example, for overuse of health care, 30 percent of children receive excessive antibiotics for ear infec- tions, 20 percent to 50 percent of many surgical interventions are unnecessary, and 50 percent of X-rays in back pain patients are unnecessary. Underuse can be seen in data that show that 50 per- cent of the elderly fail to receive the pneumococcal vaccine. Misuse is illustrated by the 7 percent of hospital patients who experience a serious medication error and the 44,000 to 98,000 Americans who die in hospitals each year due to injuries from care (Berwick, 2004). Other types of waste include administrative waste, process waste, and geographic variation in how health care is delivered. Admin- istrative waste is largely a function of the fragmented health care system and a fragmented public health system. Waste is exacerbated when a fragmented health care system interacts with the broader determinants of health. Administrative waste is one area that dem- onstrates why one should consider the levels of organization of care along with the processes and outcomes of care when considering areas for quality improvement. As outlined in the 2007 National Healthcare Quality Report (NHQR) (AHRQ, 2008a), there are also variations in the quality of care delivered across the country. The report also indicates that although health care quality is improving, the rate is slow, and safety is improving at an even slower rate. Progress is not as rapid as it should be. The 2001 Institute of Medicine (IOM) report, Crossing the Qual- ity Chasm (IOM, 2001) outlined six aims to improve the quality of health care. The six aims are that health care should be safe, effective, patient-centered, timely, efficient, and equitable. These six aims address not only process improvement but improvement that needs to occur at multiple levels within the health care system (see Figure 2-1). It is not enough to change the payment and regulatory environment; health care organizations and teams providing care must be sup- 1 Of the infant mortality rates reported for 32 developed countries, the United States had higher infant mortality than 30 other countries, ranking above only the country of Latvia (Nordquist, 2006).

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 OPPORTUNITY AT THE INTERSECTION Health Care System Outcomes: Supportive Organizations High- • Safe payment and that facilitate performing • Effective regulatory the work of patient- • Efficient environment patient-centered centered • Patient-centered teams teams • Timely • Equitable • Redesign of care processes based on best practice • Effective use of information technologies • Knowledge and skills management • Development of effective teams • Coordination of care • Incorporation of performance and outcome measurements for improvement and accountability FIGURE 2-1 The health care system. SOURCE: IOM, 2001. Figure 2-1.eps ported as well. These changes in turn will lead to better patient outcomes. The aims have led to much debate and discussion about changes in the structure and organization of care. However, the aims of patient-centeredness and equity are not as well represented by quality measures or improvement efforts as the other aims. These two aims deserve better measurement, better data, and stronger improvement efforts. It is not enough to focus on quality; disparities must be addressed as well. This is an important consideration, as health care outcomes show significant disparity by race, ethnicity, and education level. DISPARITIES Disparities are defined as “racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention” (IOM, 2003). The findings from the IOM report Unequal Treatment are summarized as follows: 1. Disparities exist and are unacceptable. 2. Disparities occur in a broader social context.

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 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS 3. There are multiple sources of disparate treatment. 4. Bias, stereotyping, prejudice, and clinical uncertainty may all play a role in health disparities. 5. Minority patients may be more likely to refuse treatment than white patients. (However, minority refusal rates do not fully explain health disparities.) The report’s recommendations on reducing health disparities include raising general awareness about disparities; legal, regula- tory, and policy interventions; health care systems interventions; public education campaigns and efforts to empower racial and eth- nic minority patients; increased amounts of cross-cultural education and training for health care professionals; better data collection and monitoring; and greater amounts of research on disparities. Unequal Treatment states that improving the consistency and quality of care via the establishment of evidence-based guidelines is an important task. Evidence-based guidelines emphasize standard- ization, while patient-centeredness suggests the need for tailoring care to individual patients. Other recommendations include the cre- ation and maintenance of payment systems to ensure an adequate supply of services to racial and ethnic minority patients, enhancing communication and trust between providers and patients via the provision of incentives for practices that reduce barriers to high- quality health care and encourage the adoption of evidence-based practices, provision of greater support of interpreter services and community health workers, and the implementation of multidisci- plinary teams for the provision of care. Despite these IOM recommendations, a more recent report, the 00 National Healthcare Disparities Report (NHDR) indicates little progress in reducing racial and ethnic health disparities (AHRQ, 2008b). In other words, there is still much progress to be made. Perhaps the best way to begin thinking about a set of priori- ties for reducing health disparities is to consider the three largest disparities in health care quality for racial and ethnic minorities as outlined in the 2007 NHDR (see Table 2-1). Taking this approach may allow for the development of some ideas in the health care commu- nity about how to begin to address these most important disparity issues in health care systems, which are beginning to collect data. One of the themes from this table is the importance of effective com- munication, as noted in the bolded sections in the table. In current quality measures, such as the Healthcare Effective- ness Data and Information Set (HEDIS) of the National Committee on Quality Assurance, current measures do not adequately measure

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 OPPORTUNITY AT THE INTERSECTION disparities. One must be careful about applying risk-adjustment methods to current performance measures. Care must be taken to ensure that in the process of risk adjustment, the differences of inter- est are not simply adjusted out. Finally, there is variation within health care organizations that compromises the delivery of quality care. This variation in health care delivery to diverse populations of patients is a legitimate target for quality improvement efforts. The generation and collection of data by racial and ethnic group category is a first step that can assist in developing quality improvement efforts. Good data are needed to build a foundation for improvement. Health care systems’ strategies to reduce disparities include setting disparities reduction goals that are then incorporated into contracts and performance incentives. For example, the HealthPart- ners system in Minnesota has goals and objectives related to both disparities reduction and the improvement of health literacy. Mea- sures of disparities and the skills to collect and assess them are also important, as is the development of additional interventions known to reduce disparities. Successful approaches should include making efforts to reach out to the local community in order to understand the context in which people live. Lastly, delivering culturally and linguistically appropriate care at all levels of the health care delivery system is important. HEALTH LITERACY The final strand for integration is health literacy, “the degree to which individuals have the capacity to obtain, process, and under- stand basic health information and services needed to make appro- priate health decisions” (Ratzan and Parker, 2000). Research shows that a substantial percentage of the American population does not have the capacity to adequately understand and use health infor- mation (IOM, 2008). Health literacy is a shared function of social and individual factors such as education, culture, and language. Additionally, health care providers need to have strong communi- cation and assessment skills as do the media, the marketplace, and government agencies—to provide health information in a manner appropriate to the intended audience. The complexity of the health care system and the way patients experience it contribute to the dif- ficulty of being health literate. Addressing health literacy is no less daunting than the task of addressing disparities.

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0 TABLE 2-1 Largest Disparities in Health Care Quality for Selected Groups: 2005 versus 2007 NHDRa 2005 NHDR 2007 NHDR Group Measure Relative rate Measure Relative rate Black New AIDS cases per 100,000 10.4 New AIDS cases per 100,000 10.0 population age 13 and over population age 13 and over Hospital admissions for pediatric 4.0 Hospital admissions for pediatric 3.8 asthma per 100,000 population ages asthma per 100,000 population ages 2–17 2–17 Percent of patients who left the 1.9 Hospital admissions for lower 3.8 emergency department without being extremity amputations in patients seen with diabetes per 100,000 population Asian Persons age 18 or older with 1.6 Composite: Adults who reported 1.6 serious mental illness who did not poor communication with health receive mental health treatment or providers counseling in the past year Adults who can sometimes or never 1.6 Long-stay nursing home residents 1.5 get care for illness or injury as soon who were physically restrained as wanted Adults age 65 and over who did 1.5 Adults age 65 and over who did 1.5 not ever receive pneumococcal not ever receive pneumococcal vaccination vaccination AI/ANb Women not receiving prenatal care in 2.1 Women not receiving prenatal care 2.1 the first trimester in the first trimester

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Composite: Adults who reported 1.8 Composite: Adults who reported 1.8 poor communication with health poor communication with health providers providers Children ages 2–17 with no advice 1.3 Women age 40 and over who 1.8 about physical activity reported they did not have a mammogram within the past 2 years Hispanic New AIDS cases per 100,000 3.7 New AIDS cases per 100,000 3.5 population age 13 and over population age 13 and over Adults who can sometimes or never 2.0 Hospital admissions for lower- 2.9 get care for illness or injury as soon extremity amputations in patients as wanted with diabetes per 100,000 population Composite: Children whose parents 1.8 Women not receiving prenatal care 2.0 reported poor communication with in the first trimester their health providers Composite: Children whose parents 3.3 Composite: Children whose parents Poor 3.0 reported poor communication with reported poor communication with their health providers their health providers Adults who can sometimes or never 2.3 Adults who can sometimes or never 2.4 get care for illness or injury as soon get care for illness or injury as soon as wanted as wanted Children ages 2–17 who did not have 2.0 Women age 40 and over who 2.1 a dental visit reported they did not have a mammogram within the past 2 years aNHDR = National Healthcare Disparities Report. bAI/AN = American Indian/Alaska Native.  SOURCE: AHRQ, 2008b.

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 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS How is health literacy considered in the context of quality improvement? Although data that assess the health literacy skills of a particular individual can be collected, there is no similar assess- ment for the health care delivery organizations. From the perspective of health literacy, the interface of the health care system with an indi- vidual is very complex, and this complexity can lead to fragmented care, different communication strategies across multiple providers, and complicated efforts that require a high level of coordination to achieve the effective management of chronic disease. The problem is twofold. First, there is the problem of the differing capability of individuals to understand health information. Second, there is the problem of the technically complex subject, language, and process of care. We lack the measurement tools to assess patient literacy in patient populations served by operating health care systems. Qual- ity measures for improving health literacy are lacking. In the United States today, 90 million people have inadequate levels of health literacy (IOM, 2008). A low level of health literacy is associated with a number of negative health outcomes, including less use of preventive services, greater use of hospitals and hospital emergency rooms, poor general health and mental health, and an increased risk of death. The IOM report Health Literacy: A Prescription to End Confusion (IOM, 2004) outlined potential interventions to address raising levels of health literacy in three areas: the health care system, the education system, and in culture and society. Low health literacy is not just a problem for the health care system; it is a broader societal issue. Figure 2-2 provides a health literacy framework for potential points. THE PERFECT STORM The Educational Testing Service predicts a 5 percent decline in health literacy for 16- to 65-year-olds, suggesting that the problem of health literacy will worsen. Ruth Parker and colleagues (2008) called a future that holds declining health literacy levels, shifting demo- graphic patterns, and a changing job market “the perfect storm.” 2 2 The high school graduation rate in the United States is stagnant and has been since the mid-1990s. The American population is increasingly diverse, owing to a large growth in the number of new immigrants. Many of these immigrants speak little or no English, and all have diverse backgrounds and educational experiences. Additionally, half of the expected job growth in the coming decade is predicted to be in “knowledge-intensive” work sections where high literacy proficiency is required. Coupled with an aging population of well-educated workers who are ready to retire, this signals a coming shortage of skilled workers (Parker et al., 2008).

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 OPPORTUNITY AT THE INTERSECTION FIGURE 2-2 Health literacy framework. SOURCE: IOM, 2003. The consequences of this perfect storm include higher numbers of unemployed and uninsured workers and even greater problems of health care quality, cost, and disparities. So how does the United States prepare for the storm? Parker et al. (2008) suggest that the following needs to occur: Use data to identify the most vulnerable populations; tailor our interventions to fit high-risk populations; simplify materials so they are tailored to the individuals being served; and, in the longer term, help build health literacy through education systems so patients can better act on their own behalf in the health care setting. Finally, it is critical that an organizational infrastructure be created to support the growing need to meet patients where they are today. Health Literacy and Health Disparities Racial and ethnic minorities are far more likely to be below basic or at basic levels in their health literacy. With the exception of Asian/ Pacific Islanders, racial and ethnic minorities are also less likely to be proficient in understanding health information. It seems clear that a lack of health literacy skills contributes to health disparities. However, it is important to note that health literacy is a problem that affects all racial and ethnic groups (see Figure 2-3). In addressing health disparities and health literacy, it is critical to deliver culturally competent and sensitive care and to reach out by engaging patients at their differing levels of capability.

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 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS Population with Basic Race/Ethnicity and Below-Basic Skills White 9 19 58 14 59,208,975 Black 24 34 41 2 20,101,750 Hispanic 41 25 31 4 23,301,839 Asian/ 13 18 52 18 3,298,968 Pacific Islander American Indian/ 25 23 45 7 1,188,458 Alaska Native Multiracial 9 28 59 3 2,525,704 80 60 40 20 0 20 40 60 80 100 Percent Below Basic Percent Basic and Above Below Basic Basic Intermediate Proficient FIGURE 2-3 Health literacyFigure 2-3.eps by race and ethnicity. Below basic is the lowest level of performance and includes tasks such as signing a form or adding redrawn the amounts on a bank deposit slip. Basic means that a person can perform simple, everyday literacy tasks such as understanding a pamphlet describ- ing how a person gets chosen for jury duty. Intermediate means that a person can do moderately challenging tasks such as identifying a specific location on a map. Proficient means that a person can perform complex activities such as interpreting a table about blood pressure and physical activity (NCES, 2005). SOURCE: AHRQ, 2008b. Poor patient–provider communication is not only a factor con- tributing to poor patient health literacy; it also is related to racial, ethnic, and income disparities (AHRQ, 2008b). Racial and ethnic minority groups were more likely to report poor communication with their health care provider. Income level, too, is a factor; lower- income groups are more likely to report poor communication. Although patient–provider communication is important, it is also worth noting that the individual spends only a small propor- tion of his total life with his physician. Rather, people are left to make health decisions on a daily basis on their own behalf. This compounds the difficulty of increasing health literacy, and, in turn, remains a significant barrier to improving health care quality.

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 OPPORTUNITY AT THE INTERSECTION Improving Disparities in Health Care and Health Literacy in Care Systems The processes of care must be reenvisioned to facilitate equi- table patient-centered care. HealthPartners developed a “care model process” that attempts to standardize care at the point of service to the patient with the objective of providing the same evidence-based high standard of care to all patients. The early experience with standardized care processes3 suggests that quality of care can be improved and disparities in care narrowed. What has not received as much attention, however, is postvisit and between-visit care. The medical home model as articulated by the primary care specialty societies may present tremendous opportunities for better coordinating the care of patients. It is possible that this model could also serve as a vehicle to reach out to patients in culturally sensitive and appropriate ways and work with them to improve their health literacy skills beyond basic or below basic levels. However, in addition to addressing the processes of care, changes in the structure of the care delivery system must also be considered. Tolen (2008) describes the nature of physician organizations as they relate to quality and efficiency of care using the structure, process, and outcome framework developed by Donabedian (1966). As was mentioned earlier, it is important to think about the complexity of the interface of the health care system in relationship to the health literacy of the individual patient. However, there has been very little discussion in health care reform about how to provide the kinds of infrastructure and support to enable health care organizations to improve quality and deal with the challenges of complex interac- tions between quality improvement, health disparities, and health literacy. Providing equitable, patient-centered, high-quality care is not only an issue of an individual clinician dealing with a patient. It is also how the health care organization is configured to deal with diverse populations and literacy issues in the context of the neigh- borhood and broader community where the clinic resides. Evidence-based medical practices help to standardize care to ensure that the same high quality is available to all. This can result in reduced disparities in care. There is also the need to customize that evidence-based standard to the culture and preferences of the individuals served and tailor the approach to maximize the outcome 3 Standardized care processes are defined as care that meets all of the desirable quality attributes as identified in Crossing the Quality Chasm (IOM, 2001).

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 TOWARD HEALTH EQUITY AND PATIENT-CENTEREDNESS for patients with all levels of health literacy skills. Changing health care systems requires more than just looking at the processes of care; the structures of care must also be considered. These structures need to have the ability to deliver better patient care that is better tailored to the individual needs of patients, both on the individual level and the population level. NExT STEPS To improve quality of health care by addressing health literacy and health disparities, the following steps need to be implemented. First, leadership and vision with explicit long- and short-term goals are critical. These goals should relate not only to health care, but also to health care disparities and health literacy. Second, care standards that reduce the existing variation in recommending evidence-based care must be implemented while recognizing that at times, care must also be customized. This involves incorporating the values and preferences of individual patients and considering their individual skills and abilities. A robust research agenda focusing on health literacy and health disparities is critical to ensure that patient-centered care becomes incorporated as a critical underpinning in all quality improvement efforts. Shared decision-making skills in the health care delivery system are critical, as is the creation and implementation of effec- tive interventions by trained teams with appropriate skills. Quality improvement through disparities reduction and improved health literacy also requires redesigned and optimized care structures and processes, coordinated and integrated care, and effective use of information technologies as a part of process redesign. It is necessary to create and use performance measures by racial or ethnic group, health literacy capability, and complexity of care interface, as well as to include incentives for improvement of performance measures. Finally, the integration of quality, disparities reduction, and health literacy requires community collaborations with both the public and private sectors.