| Review of Interventions to Reduce Racial and Ethnic Disparities in Health Care
A Systematic Review of Racial and Ethnic Disparities Intervention Literature
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Overview
Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation, conducted a review of racial and ethnic disparities intervention literature to identify successful strategies and provide health care organizations, providers and payers with recommendations on how they can address disparities in their own organizations. Published as a special supplement to the October 2007 edition of Medical Care Research and Review, the study reviewed more than 200 articles that outline interventions that have the potential to reduce racial and ethnic disparities in the areas of cardiovascular disease, diabetes, depression and breast cancer. Additionally, the research surrounding two specific approaches—cultural leverage and pay-for-performance incentives—was examined and provides insight for future intervention development.
Successful Strategies
Through the systematic review, it became clear that the following three strategies were often part of successful interventions.
Multifaceted Programs
Successful interventions often involved multiple components targeting different levers of change such as providers, patients, and the community.
A Focus on Cultural Relevancy
Culturally-tailored quality improvement approaches such as creating intervention materials (posters, pamphlets) with culturally congruent images and in languages other than English produced successful outcomes. The review found that interventions that utilized cultural leverage as a strategy to reduce disparities increased patient knowledge and understanding for self-care, decreased barriers to access, and improved multiple areas of cultural competence for health care providers.
Nurse-led Programs
Nurse-led patient-centered interventions within the context of wider systems change were found to be promising. Because nurses often spend more time with patients and can provide critical care coordination, they are in a unique position to affect change within an organization.
Key Findings
The researchers’ key findings from the reviews of literature in each disease area are as follows:
Diabetes
Most of the diabetes intervention literature focused on improvements in health care delivery and outcomes. The researchers found that effective diabetes patient interventions were culturally-tailored. Effective provider interventions incorporated one-on-one feedback and education. Successful health systems interventions effectively engaged nurse case managers and nurse clinicians.
Depression
The literature showed that multi-component chronic disease management interventions have produced improvements in depression outcomes for ethnic minority populations. Case management appears to be a key component of effective interventions and socio-culturally tailored treatment and prevention interventions may be more efficacious than standard treatment programs.
Breast Cancer
A majority of the breast cancer literature involved screening rather than diagnostic testing or treatment interventions. Among patient-targeted screening interventions, those that were culturally tailored or addressed financial or logistical barriers were generally more effective than reminder-based interventions. Chart-based reminders increased physician adherence to mammography guidelines but were less effective at increasing clinical breast examination. Case management was found to be an effective strategy for expediting diagnostic testing after screening abnormalities have been found.
Cardiovascular Disease
This review addressed cardiovascular risk factors (hypertension, hyperlipidemia, physical inactivity, tobacco), and cardiovascular conditions (coronary artery disease ,heart failure). Researchers found that most interventions focus on improving the care of African-American populations, with relatively little work in Hispanic, Asian, and American Indian populations. Promising interventions for cardiovascular disease include organization level interventions such as registries, interventions involving nurses and pharmacists, contacting patients between clinic visits, and community outreach.
Future Directions
There is still much work to be done in disparities research and in developing effective interventions. Although this review identified several promising strategies that can be built on, it also pointed to the need for additional work and areas where questions still exist.
Moving forward, disparities should be studied in underrepresented populations such as American Indian, Asian American, and pediatric ethnic and geriatric ethnic subgroups. The effect of quality improvement policies, such as pay-for-performance incentives, should be measured to promote a narrowing, as opposed to neutral or widening, effect on disparities. Funding agencies should invest in expanded and coordinated research portfolios to better explain the causes and consequences of health disparities and develop interventions to promote equitable health care and health outcomes. Policy makers should help pave the way to establishing national data structures to monitor the impact of these interventions on the quality of care patients receive.
The United States still has a great distance to travel before racial and ethnic disparities in care can be eliminated. However, there is reason for optimism based upon the early lessons from the existing literature. By enhancing knowledge and problem-solving ability in this critical area, practical solutions to end racial and ethnic disparities in health care are possible.
Articles
Jeroan J. Allison
Health Disparity: Causes, Consequences, and Change
Med Care Res Rev 2007 64: 5S -6S.
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Marshall H. Chin, Amy E. Walters, Scott C. Cook, and Elbert S. Huang
Interventions to Reduce Racial and Ethnic Disparities in Health Care
Med Care Res Rev 2007 64: 7S -28S.
Abstract PDF
Andrew M. Davis, Lisa M. Vinci, Tochi M. Okwuosa, Ayana R. Chase, and Elbert S. Huang
Cardiovascular Health Disparities: A Systematic Review of Health Care Interventions
Med Care Res Rev 2007 64: 29S -100S.
Abstract PDF
Monica E. Peek, Algernon Cargill, and Elbert S. Huang
Diabetes Health Disparities: A Systematic Review of Health Care Interventions
Med Care Res Rev 2007 64: 101S -156S.
Abstract PDF
Benjamin W. Van Voorhees, Amy E. Walters, Micah Prochaska, and Michael T. Quinn
Reducing Health Disparities in Depressive Disorders Outcomes between Non-Hispanic Whites and Ethnic Minorities: A Call for Pragmatic Strategies over the Life Course
Med Care Res Rev 2007 64: 157S -194S.
Abstract PDF
Christopher M. Masi, Dionne J. Blackman, and Monica E. Peek
Interventions to Enhance Breast Cancer Screening, Diagnosis, and Treatment among Racial and Ethnic Minority Women
Med Care Res Rev 2007 64: 195S -242S.
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Thomas L. Fisher, Deborah L. Burnet, Elbert S. Huang, Marshall H. Chin, and Kathleen A. Cagney
Cultural Leverage: Interventions Using Culture to Narrow Racial Disparities in Health Care
Med Care Res Rev 2007 64: 243S -282S.
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Alyna T. Chien, Marshall H. Chin, Andrew M. Davis, and Lawrence P. Casalino
Pay for Performance, Public Reporting, and Racial Disparities in Health Care: How Are Programs Being Designed?
Med Care Res Rev 2007 64: 283S -304S.
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