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Disparities in Health Care Quality Among Racial and Ethnic Minority Groups

Findings From the National Healthcare Quality and Disparities Reports, 2008

Fact Sheet


Since 2003, the Agency for Healthcare Research and Quality has produced the National Healthcare Quality Report and the National Healthcare Disparities Report. Despite improvements, differences persist in health care quality among racial and ethnic minority groups. People in low-income families also experience poorer quality care. This fact sheet discusses differences between groups in terms of relative rates, which is the ratio of the comparison group (e.g., Black) to a baseline group (e.g., White).

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Contents

Introduction
Disparities Persist in Health Care Quality and Access
Magnitude and Patterns of Disparities Differ Among Various Populations
Some Disparities Exist Across Multiple Priority Populations
Limited English Proficiency Is a Barrier to Quality Health Care
Poverty Is a Barrier to High-Quality Care
Disparities Reports Charts Related to Racial and Ethnic Minorities
For More Information

 

Introduction

Since 2003, the Agency for Healthcare Research and Quality (AHRQ) has produced the National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR). Although improvements have been seen in health care quality and some disparities have been reduced or eliminated, differences persist in health care quality among members of various racial and ethnic minority groups.

Three key themes emerge in the 2008 NHDR:

  • Disparities persist in health care quality and access.
  • Magnitude and patterns of disparities are different within subpopulations.
  • Some disparities exist across multiple priority populations.

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Disparities Persist in Health Care Quality and Access

All population groups should receive equally high quality of care. Getting into the health care system (access to care) and receiving appropriate health care in time for the services to be effective (quality of care) are key factors in ensuring good health outcomes. Both categories of measures, quality of care and access to care, show that disparities persist for all populations. Measures of quality include effectiveness (the percentage of patients with a disease or condition who get recommended care), patient safety, and timeliness.

Below are figures that illustrate for each population how disparities in quality and access have changed in the past 5 years. In each figure, "n" indicates the number of core measures. Figure 1 shows that for Blacks, Asians, American Indians/Alaska Natives (AI/ANs), and Hispanics, at least 70% of measures of quality of care are not improving (either stayed the same or worsened).

Many Americans have access to primary and hospital care. For many populations, however, barriers exist to getting needed health care, such as lack of health insurance or trouble getting appointments. Reducing disparities in access to health care is an important step to improving overall quality. Figure 2 is a summary of trends in the core measures of access.

 

Figure 1. Change over time in racial and ethnic disparities for selected core quality measures, 2000-2001 to 2005-2006

 

Figure 2. Change over time in racial and ethnic disparities for selected core access measures, 2000-2001 to 2005-2006

Key: AI/AN = American Indian or Alaska Native.

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Magnitude and Patterns of Disparities Differ Among Various Populations

Improvements in preventive care, chronic care, and access to care have led to the elimination of disparities for some priority populations in areas such as mammograms, smoking cessation counseling, and appropriate timing of antibiotics. At the same time, many of the largest disparities have not changed significantly. The NHDR can be used to identify the most important gaps in care as well as improvements for priority populations. The complete picture of disparities is different for each population. An analysis of each population allows targeting of resources and efforts to improve care and narrow the gaps in care for racial and ethnic minorities.

In 2005, the NHDR reported on the biggest gaps that existed in health care quality in America for several priority populations, including Blacks, Asians, AI/ANs, and Hispanics. Some of the largest gaps reported in 2005 remain the largest gaps in the 2008 NHDR.

  • For Blacks, large disparities remain in new AIDS cases despite significant decreases. The proportion of new AIDS cases was 9.4 times as high for Blacks as for Whites. Hospital admissions for lower extremity amputations in patients with diabetes and lack of prenatal care for pregnant women in the first trimester are the largest disparities for Blacks observed in the 2008 NHDR.
  • For Asians, disparities remain in timeliness of care. Asians were more likely than Whites to not get care for illness or injury as soon as wanted.
  • For AI/ANs, disparities remain in prenatal care. AI/AN women were twice as likely to lack prenatal care as White women. Also, AI/AN adults were less likely than Whites to receive colorectal cancer screening.
  • For Hispanics, large disparities also remain in new AIDS cases despite significant decreases. The rate of new AIDS cases was more than three times as high for Hispanics as for non- Hispanic Whites.

The "biggest gaps" are defined as those quality measures with the largest relative rates between Whites and racial and ethnic minorities. For example, a relative rate of 4.0 means that this population was four times as likely as the White population to be hospitalized for pediatric asthma. This analysis is presented in Table 1.

 

Table 1. Three largest disparities in quality of health care for selected groups: Measure and rate relative to reference group, 2005 NHDR versus 2008 NHDR (Measures that have the largest gaps in both the 2005 and 2008 NHDR are in italics.)

2005 NHDR 2008 NHDR
Group Measure Relative rate Measure Relative rate
Black compared with White New AIDS cases per 100,000 population age 13 and over 10.4 New AIDS cases per 100,000 population age 13 and over 9.4
Hospital admissions for pediatric asthma per 100,000 population ages 2-17 4.0 Hospital admissions for lower extremity amputations in patients with diabetes per 100,000 population 2.3
Emergency department visits in which patients left without being seen 1.9 Pregnant women who did not receive prenatal care in the first trimester 1.6
Asian compared with White People age 18 and over with serious mental illness who did not receive mental health treatment or counseling in the past year 1.6 Adults who can sometimes or never get care for illness or injury as soon as wanted 2.1
Adults who can sometimes or never get care for illness or injury as soon as wanted 1.6 Children ages 2-17 who did not receive advice about physical activity 1.2
Adults age 65 and over who did not ever receive pneumococcal vaccination 1.5 Adults age 65 and over who did not ever receive pneumococcal vaccination 1.6
AI/AN compared with White Pregnant women who did not receive prenatal care in the first trimester 2.1 Pregnant women who did not receive prenatal care in the first trimester 2.1
Composite: Adults who reported poor communication with health providers 1.8 Adults age 50 and over who received colorectal cancer screening 1.4
Children ages 2-17 who did not receive advice about physical activity 1.3 Home health care patients who were admitted to the hospital 1.3
Hispanic compared with non-Hispanic White New AIDS cases per 100,000 population age 13 and over 3.7 New AIDS cases per 100,000 population age 13 and over 3.3
Adults who can sometimes or never get care for illness or injury as soon as wanted 2.0 Composite: Children whose parents reported poor communication with health providers 2.0
Composite: Children whose parents reported poor communication with health providers 1.8 Pregnant women who did not receive prenatal care in the first trimester 2.0
Poor compared with high income Composite: Children whose parents reported poor communication with health providers 3.3 Composite: Children whose parents reported poor communication with health providers 3.7
Adults who can sometimes or never get care for illness or injury as soon as wanted 2.3 Adults who can sometimes or never get care for illness or injury as soon as wanted 2.5
Children ages 2-17 who did not have a dental visit 2.0 Women age 40 and over who reported they did not have a mammogram in the last 2 years 2.1

Note: Relative rate is used to compare one group with its reference group. It is calculated by dividing the group's estimate by the reference group's estimate. For example, the relative rate of new AIDS cases for Blacks compared with Whites is 9.4 in the 2008 NHDR. This means that Blacks have a rate that is 9.4 times as high as Whites for this measure.

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Some Disparities Exist Across Multiple Priority Populations

In addition to the variable distribution of disparities evident across priority populations, in some cases several different populations experience the same gaps in care as other populations due to poor quality overall or populations experiencing similar barriers. The following measures included in the NHDR illustrate disparities for two or more populations:

  • Blacks, Asians, AI/ANs, and Hispanics all experienced disparities in the percentage of adults age 50 and over who received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test. For this measure, between 1999 and 2006, the disparity increased in all four groups (Table 2).
  • For Blacks and Hispanics, disparities grew larger in the percentage of adults with a major depressive episode in the last 12 months who received treatment for depression in the last 12 months.
  • Blacks and Asians both had worsened disparities in the receipt of pneumococcal vaccination for adults age 65 and over.
  • Blacks and Asians both had worsened disparities in a patient centeredness measure of patient and provider communication.

 

Table 2. Core measures that are getting worse for more than one racial and ethnic group compared with reference group

Topic Measure Blacks Asians AI/ANs Hispanics
Cancer Adults age 50 and over who received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test * * * *
Mental health and substance abuse Adults with a major depressive episode in the last 12 months who received treatment for depression in the last 12 months *     *
Respiratory diseases Adults age 65 and over who ever received pneumococcal vaccination * *    
Patient centeredness Adults with poor provider-patient communication * *    

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Limited English Proficiency Is a Barrier to Quality Health Care

Limited English proficiency is a barrier to quality health care for many Americans. About 52 million Americans, or 19.4% of the population, spoke a language other than English at home in 2000, up from 32 million in 1990. Of the 52 million:

  • 32 million (about 12% of the population) spoke Spanish.
  • 10 million (about 4% of the population) spoke another Indo- European language.
  • 7.8 million (about 3% of the population) spoke an Asian or Pacific Islander language, and
  • 2 million spoke other languages at home.

Many of these people lack health insurance. Figure 3 shows the percentage of adults under age 65 who were uninsured all year, stratified by language spoken at home.

 

Figure 3. Adults under age 65 who were uninsured all year, by race and ethnicity, stratified by language spoken at home, 2005

Clear communication is an important component of effective health care delivery. It is vital for providers to understand patients' health care needs and for patients to understand providers' diagnoses and treatment recommendations. Communication barriers can relate to language, culture, and health literacy.

For people with limited English proficiency, having language assistance is of particular importance. People with limited English proficiency may choose a usual source of care in part based on language concordance. Not having a language concordant provider may limit or discourage some patients from establishing a usual source of care. Figure 4 shows the percentage of adults with limited English proficiency who had a usual source of care with language assistance.

 

Figure 4. Adults with limited English proficiency, by whether they had a usual source of care with or without language assistance, 2003-2005

Key: USC = usual source of care.

Note: Language assistance includes bilingual clinicians, trained medical interpreters, and informal interpreters (e.g., bilingual receptionists).

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Poverty Is a Barrier to High-Quality Care

In general, poor populations have reduced access to high-quality care and are more likely to be uninsured. Figure 5 shows that poor populations have worse care and less access to care than high-income populations.

 

Figure 5. Poor compared with high-income individuals on measures of quality and access

Key: CRM = core report measures.

Although some disparities between poor people and high-income people in access to care are lessening, most measures of quality that could be tracked over time show no improvement. Figure 6 shows changes in poor-high-income disparities over time.

 

Figure 6. Change in poor-high-income disparities over time

Key: CRM = core report measures.

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Disparities Reports Charts Related to Racial and Ethnic Minorities

The measures in the NHDR are presented by clinical condition or area (e.g., cancer, diabetes, maternal and child health) in Chapter 2 and by priority population (e.g., Blacks, Hispanics) in Chapter 4. The NHDR highlights findings on a selected number of measures each year. Additional data on measures relevant to racial and ethnic minorities can be found in the online data tables for the report.

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For More Information

The 2008 National Healthcare Disparities Report (AHRQ Pub. No. 09-0002) is available online at http://www.ahrq.gov/qual/qrdr08.htm.

Printed copies of the report can be ordered from the AHRQ Publications Clearinghouse by calling 800-358-9295 or by sending an e-mail to AHRQPubs@ahrq.hhs.gov.

Additional information on programs and activities related to minority health at the Agency for Healthcare Research and Quality is available on the AHRQ Web site at http://www.ahrq.gov/research/minorix.html or by contacting:

Cecilia Rivera Casale, Ph.D.
Senior Advisor for Minority Health
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
Phone: (301) 427-1547
Fax: (301) 427-1562
E-mail: Cecilia.Casale@ahrq.hhs.gov

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Current as of September 2009
Internet Citation: Disparities in Health Care Quality Among Racial and Ethnic Minority Groups: Findings From the National Healthcare Quality and Disparities Reports, 2008. September 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqrdr08/minority.html