The ability to deliver a consistent product and outcome is a defining factor of a “high-reliability” system. The persistence of health care disparities based on race/ethnicity, income, sex or sexual orientation, and residence is a stark reminder that health inequity is pervasive in the United States and that our health care system is far from becoming a highly reliable system. Moreover, there is increasing recognition that factors outside of health care are among the strongest determinants of health disparities. Although health care reforms have narrowed disparities in access, disparities remain for many health outcomes related to chronic disease and mental health as well as for most processes of care.1 It seems timely to reflect from our positions at 2 major funders of disparities research, the US Department of Veterans Affairs (VA) and National Institutes of Health (NIH), on future directions of this field of research. We recognize that a focus on individual interactions at the level of the health care system needs to be matched with attention at the community and societal level.
The experience of the VA provides a window into how much an integrated health care delivery system can do to reduce disparities through a combination of access to care, social supports, integration of behavioral health and primary care, and outreach to vulnerable populations. The good news is that VA has made substantial progress in eliminating some of the racial and ethnic disparities seen outside VA for conditions such as blood pressure control, receipt of mental health care, and cancer outcomes. A recent review of 362 studies examining disparities in quality of care in Veteran populations,2 however, presented a mixed picture depending on whether disparities were measured in terms of utilization, quality/process, or health outcome. Utilization among Veterans cared for by the VA did not vary consistently based on race/ethnicity, sex, mental health conditions, or age but was lower for those living in rural areas. On process measures, important gaps remain in terms of satisfaction with care, adherence with medications, treatment of pain, and use of surgical procedures. Finally, for Veteran health outcomes, low socioeconomic status was a more consistent source of disparate health outcome than race, ethnicity, sex, rural residence or mental health conditions. This is consistent with the recent reports of rising morbidity and mortality seen among lower-income whites in the United States.3
Taken together, these findings reinforce that health disparities have complex roots outside the health system. These include the multiple economic, cultural, and social factors that contribute to inequality and social disadvantage as well as individual behavioral and biological differences. Research conducted by VA and NIH on underlying contributors to the disparities suggests different targets, or mechanisms, for interventions to improve health equity and reduce disparities.
First, at the individual level, disparities may exist because of gaps in knowledge or health literacy that make it harder for disadvantaged patients to navigate the health system. Notably, for joint replacement, VA research has found that low rates of surgery in African Americans with severe arthritis could be improved with a targeted, patient-centered educational intervention.4 Other research has used peer support effectively to help minority patients with poorly controlled diabetes and to help mental health patients who were reluctant to engage with VA care.5 The NIH-sponsored Diabetes Prevention Program showed that a lifestyle modification intervention leading to modest weight loss and increased physical activity reduced progression of prediabetes to diabetes by 58% compared with metformin and placebo over 3 years in 3234 participants of whom 45% were from minority groups.6 Limited English proficiency is a modifiable communication barrier, with evidence that using professional interpreters may help reduce errors in communication and result in better patient outcomes following discharge.7
The second level of intervention is at the level of clinician. Ongoing VA and NIH studies are testing cultural competency interventions to improve care. An NIH study showed that giving greater choice to diverse patients in colon cancer screening resulted in higher completion rates. The third level—the health care system—is a more challenging target for intervention, especially when observed disparities are attributable to facility or community-level factors. For example, nearly half of the black:white difference in maternal morbidity in New York may be attributable to the fact that white mothers were much more likely to deliver in hospitals with low overall maternal morbidity (ie, better performing hospitals).8
Several areas ripe for research and collaboration address mechanisms of disparities across individual, clinician, and health system/community characteristics. Because individuals spend much more time managing their health at home than interacting with the health care system, addressing social determinants of health will require taking advantage of community-level organizations (eg, churches, small businesses, social groups) to engage patients in their care. One promising approach is the use of community health workers to deliver behavioral interventions for management of chronic disease, an approach that can decrease depressive symptoms and improve health status.9 Another is implementing mobile technology for self-management of diabetes.
Clinicians may experience a tension between providing patient-centered care that respects individual preferences and addressing disparities created in part by limited understanding about the safety and efficacy of proposed treatments because of limited health literacy or other communication barriers. The desire to engage patients in decisions about their health does not mean clinicians should abstain from advocating strongly for what they think is the best option, which most patients expect and value. We need to appreciate that patients may truly have different and valid values for distinct health outcomes, while supporting clinicians to provide the most effective information to inform those values.
Progress in chronic disease management has been facilitated by an ability to accurately measure performance and a process to measure and reward progress. Accurately measuring performance and progress are harder in the effort to narrow health disparities, as existing health records do not consistently capture the different social determinants that influence health outcomes. Value-based, alternative payment models that reward providers for maintaining or improving the health of their patients may provide better incentives for investing in population health approaches that can reduce health inequity.10 Making progress against disparities a measure of health system performance could also help shift attention to improving outcomes in disadvantaged groups. It could also protect medical practices and health systems that care for disadvantaged populations from being penalized for societal factors outside their control.
Finally, for health systems and communities at large, more research is needed to identify effective implementation strategies that put into place evidence-based treatments and policies to reduce disparities, especially in lower-resourced, community-based settings. Implementation strategies, which are the “how” of implementation science, are highly specified processes used to support providers, health systems, and communities to promote the uptake of evidence-based practices. The VA’s Quality Enhancement Research Initiative (QUERI) has funded a national network of centers devoted to the use of implementation strategies that support the rapid deployment of evidence-based practices into routine care, including for vulnerable populations including homeless, rural Veterans, those with serious mental illness, and women.11 VA’s Partnered Evidence-based Policy Resource Center is also supporting national randomized evaluations of health policies designed to reduce disparities in opioid misuse, suicide, geriatric services, and access to specialty care.12 NIH is working to expand the use of pragmatic clinical trials to support more rapid implementation of evidence-based practices in routine care settings through the NIH Health Care Systems Research Collaboratory initiative.
Together, VA and NIH are poised to support the next generation of health disparities research, with an eye towards improving health equity by understanding and intervening on individual, provider, and system barriers to care.13 Given the interdependence between health systems and population health factors, we need more research on strategies to promote stronger connections between health care facilities and community resources, improved implementation strategies, and use of evidence-based policy to reduce health disparities.
1. Agency for Healthcare Research and Quality. 2015 National Healthcare Quality and Disparities Report and 5th Anniversary Update on the National Quality Strategy. 2016. Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://www.ahrq.gov/research/findings/nhqrdr/nhqdr15/index.html
. Accessed July 18, 2017.
2. Kondo K, Low A, Everson T, et al. Health disparities in veterans: a map of the evidence. Med Care. 2017;55(suppl 2):S9–S15.
3. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci. 2015;112:15078–15083.
4. Ibrahim SA, Blum M, Lee GC, et al. Effect of a decision aid on access to total knee replacement for black patients with osteoarthritis of the knee: a randomized clinical trial. JAMA Surg. 2017;152:e164225.
5. Hausmann LR, Ren D, Sevick MA. Racial differences in diabetes-related psychosocial factors and glycemic control in patients with type 2 diabetes. Patient Prefer Adherence. 2010;4:291–299.
6. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393–403.
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8. Howell EA, Egorova NN, Balbierz A, et al. Site of delivery contribution to black-white severe maternal morbidity disparity. Am J Obstet Gynecol. 2016;215:143–152.
9. Wagner JA, Bermudez-Millan A, Damio G, et al. A randomized, controlled trial of a stress management intervention for Latinos with type 2 diabetes delivered by community health workers: Outcomes for psychological wellbeing, glycemic control, and cortisol. Diabetes Res Clin Pract. 2016;120:162–170.
11. Kilbourne AM, Elwy AR, Sales AE, et al. Accelerating research impact in a learning health care system: VA’s quality enhancement research initiative in the choice act era. Med Care. 2016;55(Suppl 1):S4–S12.
12. Atkins D, Kilbourne AM, Shulkin D. Moving from discovery to system-wide change: the role of research in a learning health care system: experience from three decades of health systems research in the Veterans Health Administration. Annu Rev Public Health. 2017;38:467–487.
13. Kilbourne AM, Switzer G, Hyman K, et al. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health. 2006;96:2113–2121.