Health disparities, revisted

Matthew Holt has an interesting editorial from Brian Smedley on the recent health disparities study:

This view, however, squarely contradicts what the vast majority of research studies have found for decades – that some patients, most notably African Americans, Latinos, those who don't speak English well, and in some cases, women – receive a lower quality of health care than their counterparts, even when they have similar health insurance and are treated for the same health conditions in the same hospitals. This applies across the gamut of health care, ranging from basic services such as screening and immunization, to primary care, to more expensive, high-tech, specialty procedures.

 

These are the conclusions of literally hundreds of studies published in peer-reviewed journals over the last two decades.  And while a few studies, such as the Asch study, find that disparities are diminishing or that all groups receive equal (albeit poor) treatment, their findings must be considered relative to the massive volume of evidence to the contrary. Even the U.S. Department of Health and Human Services' National Healthcare Disparities Report, released in January and which represents the most comprehensive survey of its kind, finds that, despite some areas of improvement, racial and ethnic healthcare disparities persist, and are worsening in some areas.   For example, the NHDR found that Latino patients with diabetes are receiving poorer quality care today than they were even a few years ago. 

Smedely doesn't discuss where the research disparity comes from, but clearly there's something to think about here.  Asch's study may very well be abberration, but the bottom line is that quality of care is poor, and everything else tells us it's even worse for the actual poor.   Also, remember again that Asch's study only looked at what happens after patients get to the hopsital -- it says nothing about those who can't afford care. 

Comments

[lag2]

I agree that the take-home point is that quality for everyone is poor.

Asch et al note that when they limited the quality indicators to those conditions/treatments previously identified as areas of disparity (e.g. cardiovascular procedures), the race/ethnicity trend is slightly tipped in the other direction, i.e. confirming these findings.

What may be missed from the publicity is the crucial point that glaring, significant health _outcomes_ disparities exist to a much greater extent. Clearly, our society is failing our poor and minority groups on many levels, and by the time they reach the health care system, it may be too late.

To say that healthcare quality is "poor" is a relative statement. I can say that the quality of accounting procedures in this country is also "poor" but thats really a meaningless statement because you need to compare it to something else.

I dont think you can look at it in a vaccuum. I think you have to compare it to other nations such as those in Europe.

The study argues that we should be spending MORE money treating people. We already spend the most money of any nation on earth, and this study seems to claim that its not good enough and that we need to spend even MORE money.

I disagree with that conclusion, but without comparison to other nations you really cant decide the best course of action.

One other note about the original study.

I think its flawed from the aspect that it its too simplistic. For example, one of the metrics of "quality" that it used was that absolutely everyone with an MI should get a beta blocker ASAP.

First off, thats patently false. If the only comorbid condition that the patient has is MI, then yes, give beta blockers. But if they have other comorbid conditions, then giving beta blockers is absolutely contraindicated. For example you would never give a beta blocker to an asthmatic or else you could kill them.

[lag2]

To clarify:
1."Quality of care," as used by their metrics refers to quality in comparison to recommended standards by a national specialty panel. In fact, these RAND metrics have been to assess the UK NHS as well (also suboptimal).
It is not relative to quality of care in say, developing countries.

2. Using definition 1., quality does not necessarily equal "more money." one of the reasons that patients with private insurance can have poor measures includes those who receive inappropriately excessive care.

3. Physicians will always argue against quality standards because of the comorbidities (and allergies, contraindications, etc.). Until there is a good study showing how often exceptions happen, it will be difficult to judge. however, i am going to guess that it's not 50% of the time.

"quality does not necessarily equal "more money"

According to the RAND study it does.

The RAND study criticism is that we arent doing ENOUGH for patients who are sick. The whole conclusion of the RAND study is that patients are not getting the right amount of care htey need.