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Integrated Framework forIntegrated Framework for
Reducing Racial andReducing Racial andEthnic Disparities in theEthnic Disparities in the
Quality of Health CareQuality of Health Care
Marshall H. Chin, MD, MPH, and Don Goldmann, MDMarshall H. Chin, MD, MPH, and Don Goldmann, MD
University of Chicago, Institute for HealthcareUniversity of Chicago, Institute for Healthcare
ImprovementImprovement
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RoadmapRoadmap
Context and problems in current efforts toContext and problems in current efforts to
reduce disparities in health care qualityreduce disparities in health care quality
Conceptual models for reducing disparitiesConceptual models for reducing disparitiesEvidence on disparity interventionsEvidence on disparity interventions
6 key components for reducing disparities6 key components for reducing disparities
Implications for fundersImplications for fundersExercise: Advice to AHRQExercise: Advice to AHRQ
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Promising TimePromising Time
Increased public awareness of disparitiesIncreased public awareness of disparities
Health reform legislation will increaseHealth reform legislation will increase
collection of race, ethnicity, and languagecollection of race, ethnicity, and languagedatadata
Increased motivation for providers andIncreased motivation for providers and
health care organizations to addresshealth care organizations to address
disparitiesdisparities
An opportunity to move from descriptionAn opportunity to move from description
and complaint to actionand complaint to action
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Problems and GapsProblems and Gaps
Lots of research on the magnitude ofLots of research on the magnitude of
disparities, but relatively little work ondisparities, but relatively little work on
interventionsinterventions to reduce disparitiesto reduce disparities
Many providers, organizations, and policyMany providers, organizations, and policy
makers do not know where to start tomakers do not know where to start to
reduce disparitiesreduce disparities
Despite language encouraging proposalsDespite language encouraging proposals
on vulnerable populations, many publicon vulnerable populations, many public
and private funders receive fewand private funders receive few
applicationsapplications
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Models, Models, ModelsModels, Models, Models
Models can inform approaches toModels can inform approaches to
disparities, but.disparities, but.
Models must be customized to addressModels must be customized to address
the unique underlying causes of disparitiesthe unique underlying causes of disparitiesdirectly, but.directly, but.
Customized solutions are sparse,Customized solutions are sparse,
therefore.therefore.The nations research agenda must beThe nations research agenda must be
directed at testing interventions thatdirected at testing interventions that
address disparities specificallyaddress disparities specifically
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Level of Engagement Model
Patient/Person
Provider
Microsystem - small unit of care delivery
Organizations that house or supportmicrosystems
Communities and regions that span care
delivery, prevention, and health promotion forpopulations
Environment of policy, payment, regulation,
accreditationBased on Berwick, Health Affairs 2002;21:n. 3
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Informed,
ActivatedPatient
Productive
Interactions
Prepared,
ProactivePractice Team
Functional and Clinical Outcomes
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Self-
Management
Support
Health SystemResources and Policies
CommunityOrganization of Health Care
Wagner
Planned Care Conceptual ModelPlanned Care Conceptual Model
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Finding Answers: Disparities Research for Change
www.SolvingDisparities.org
New IOM FrameworkCro
sscutting
Dimen
sions
EQ
U
ITY
VAL
UE
Components of
Quality Care
Type of Care
Chronic conditionmanagement
Acute
Treatment
Preventive
Care
Effectiveness
Safety
Timeliness
Patient/family-centeredness
Care Coordination
Health Systems Infrastructure Capabilities
Access
Efficiency
Crossc
utting
Dimen
sions
EQ
U
ITY
VAL
UE
Components of
Quality Care
Type of Care
Chronic conditionmanagement
Acute
Treatment
Preventive
Care
Effectiveness
Safety
Timeliness
Patient/family-centeredness
Care Coordination
Health Systems Infrastructure Capabilities
Access
Efficiency
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RWJF Finding AnswersRWJF Finding Answers
Conceptual ModelConceptual ModelChin et al. Med Care Res Rev 2007; 64:7SChin et al. Med Care Res Rev 2007; 64:7S--28S28S
Provider
Patient
Policy / Payment / Regulation / Accreditation
Health Care
Organization
Person
Community
Process
Outcomes
Access
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Systematic ReviewsSystematic Reviews
Reviewed 200+ articlesReviewed 200+ articles
ConditionCondition--specificspecific
Cardiovascular diseaseCardiovascular disease
DiabetesDiabetes
DepressionDepression
Breast cancerBreast cancer
CrossCross--cuttingcuttingCultural leverageCultural leverage
PayPay--forfor--performance incentivesperformance incentives
FAIR DatabaseFAIR Database
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Common Successful InterventionsCommon Successful Interventions
from SystematicR
eviewsfrom SystematicR
eviewsMultifactorialMultifactorial interventions that addressinterventions that addressmultiple leverage points along a patientsmultiple leverage points along a patientspathway of carepathway of care
Culturally tailored QI more than generic QICulturally tailored QI more than generic QI
NurseNurse--led interventions withled interventions with
multidisciplinary teams and close trackingmultidisciplinary teams and close trackingand monitoring of patientsand monitoring of patients
Chin MH, etal. MedCare Res Rev 2007; 64:7S-28S.
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Review of Pediatric LiteratureReview of Pediatric Literature
(Asthma, Immunizations)(Asthma, Immunizations)
Measure and improve structural aspectsMeasure and improve structural aspects
of care experience that impact outcomesof care experience that impact outcomesIncorporate families into interventionsIncorporate families into interventions
Integrate nonIntegrate non--health care partners intohealth care partners into
QI interventionsQI interventions
Chin MH, etal. Pediatrics 2009;124 (Suppl3):S224-S236.
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Lessons fromLessons from
RWJF Finding Answers: DisparitiesRWJF Finding Answers: Disparities
Research for Change GranteesResearch for Change Grantees
Knowledge/attitude interventions helpful but notKnowledge/attitude interventions helpful but not
sufficientsufficient
Providing disparity data helpful but not sufficientProviding disparity data helpful but not sufficient
Context and tailoring are criticalContext and tailoring are critical
MultifactorialMultifactorial,, multitargetmultitarget interventionsinterventions
Intervention & the process of implementationIntervention & the process of implementation
BuyBuy--in, incentives, sustainability, systemin, incentives, sustainability, system
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Integral Components of Systems Approach
to Reducing Disparities
1) Examine your performance data stratified byinsurance status, race/ethnicity, language, andsocioeconomic status.
2) Get training for your staff to work effectivelywith diverse populations.
3) Make reduction of inequities in care for
vulnerable populations an integral componentof quality improvement efforts.
Chin MH. Ann Intern Med 2008; 149:206-208.
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Systems Approach - 2
4) Provide models of care and infrastructuralsupport to enable organizations to improvethe quality of care for vulnerable patients.
5) Align incentives to reward providers andhealth care organizations for providing highquality care to vulnerable populations.
6) Allocate more resources for the uninsuredwith chronic diseases.
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Implications for FundersImplications for Funders
Move beyond asking applicants simply to showMove beyond asking applicants simply to showthat they have included priority populations inthat they have included priority populations in
their research plantheir research plan
Ask all quality of care applicants to addressAsk all quality of care applicants to address
specifically how they will reduce known disparitiesspecifically how they will reduce known disparities
or gaps discovered in the course of the workor gaps discovered in the course of the work
Include a measurement plan that stratifies dataInclude a measurement plan that stratifies data
appropriatelyappropriately
Design an overall portfolio of grants and granteesDesign an overall portfolio of grants and grantees
that addresses improving outcomes and reducingthat addresses improving outcomes and reducing
gaps in diverse populations and settingsgaps in diverse populations and settings
Reward applicants who address equity issuesReward applicants who address equity issues
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Spheres of Influence forSpheres of Influence for
Disparity InterventionsDisparity InterventionsPatient/personPatient/person
ProviderProvider
MicrosystemMicrosystemHealth care delivery organizationHealth care delivery organization
Community and regionCommunity and region
Policy, payment, regulation, accreditationPolicy, payment, regulation, accreditationWhich spheres are you addressing or plan
to address in your comprehensive,
multifactorial approach to reducing an equity gap ?
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ExampleExample -- Care CoordinationCare Coordination
for Chronically Ill Patientsfor Chronically Ill Patients
Patient: engagement, empowerment, mobilizationPatient: engagement, empowerment, mobilization
Provider: engagement, training in health literacyProvider: engagement, training in health literacy
and cultural competencyand cultural competencyMicrosystemMicrosystem: teamwork, communication,QI,: teamwork, communication,QI,
practice redesign, stratified data and real timepractice redesign, stratified data and real time
feedbackfeedback
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Care CoordinationCare Coordination
for Chronically Ill Patientsfor Chronically Ill Patients -- 22
Health care delivery organization:Health care delivery organization:
communication, coordination, support forcommunication, coordination, support for
patients and families across the continuum,patients and families across the continuum, teletele--
health and monitoring, focus on value andhealth and monitoring, focus on value andlonger term fiscal horizonlonger term fiscal horizon
Community: activation, mobilization of nonCommunity: activation, mobilization of non--
medical resources and supports, attention tomedical resources and supports, attention to
social capital and environmentsocial capital and environment
PolicyPolicy alignment of incentives and payment toalignment of incentives and payment to
promote the above actionspromote the above actions
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Exercise:
Advice to AHRQ
Request For Applications
Think of your research area
Pick one of the 6 spheres of influence
Write a research question youd like to be a priorityarea for the RFA for your research area in that sphere
of influence
If time, write questions for other spheres
To reduce disparities in health care quality, whatelse might AHRQ do, in addition to directing and
supporting research on specific topics?
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Spheres of Influence forSpheres of Influence for
Disparity InterventionsDisparity InterventionsPatient/personPatient/person
ProviderProvider
MicrosystemMicrosystemHealth care delivery organizationHealth care delivery organization
Community and regionCommunity and region
Policy, payment, regulation, accreditationPolicy, payment, regulation, accreditation