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EXECUTIVE SUMMARY
Dispanties in health care are among this nation's most serious
health care problems. Research has extensively documented the
pervasiveness of racial and ethnic disparities. Minorities receive
poorer quality care in such important areas as cardiovascular disease,
cancer, asthma, and diabetes (IOM, 2002b). Research has also
extensively documented geographic disparities, with levels of health
care quality varying by region and state (Dartmouth Atlas of Health
Care Working Group, 1999; Jencks et al., 2000~. Socioeconomic
disparities are also quite common: millions of low income Americans
lack insurance and receive poorer health care quality overall (IOM,
2002a).
As part of a national effort to eliminate health care disparities,
Congress in 1999 required the Agency for Healthcare Research and
Quality (AHRQ) to produce a new annual report to be called the
National Healthcare Disparities Report (NHDR). The first edition of
the NHDR will be published in fiscal year 2003 (October I, 2002 to
September 30, 2003~. Beginning in fiscal year 2003, AHRQ wall
produce another annual report mandated by Congress, the National
Healthcare Quality Report. Together, these reports wait call attention
to the "inequality of quality" (:FiscelIa et al., 2000, p. 2579~. Quality
can be defined as "the degree to which health services for individuals
and populations increase the likelihood of desired health outcomes and
are consistent with current professional Imowledge" (IOM, 1990, p.
211.
AHRQ commissioned the Institute of Medicine (IOM) to
establish a committee to provide guidance on the NHDR in the areas
of access to health care, utilization of services, and the quality of
services received. The committee was asked to consider such
population characteristics as race and ethnici~cy,1 socioeconomic
1 Race and ethnicity are defined using the categories in tibe Office of
Management and Budget (OMB) Directive 15: American Indian or Alaska
1
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2 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
status,2 and geographic location. It was also asked to examine factors
that included possible data sources and types of measures for the
report.
The Committee for Guidance in Designing a National
Healthcare Disparities Report was created in 2001. It focused on five
areas critical to the NHDR:
1. Measurement of socioeconomic status in
disparities research;
2. Measurement of disparities in health care services and quality;
3. Measurement of disparities in health care access;
4. Measurement of geographic units in disparities research; and
5. Subnational datasets.
Guiding the National Healthcare Disparities Report
While socioeconomic status is not the only factor related to
racial and ethnic health care disparities, it is a highly important one
because racial and ethnic minorities are more likely to have lower
socioeconomic status. Using socioeconomic status as a s~atifier in
collecting data and as a control in analysis would more clearly indicate
the extent to which disparities result from racial and ethnic factors
rather than from socioeconomic status. It should be noted that
adjusting for socioeconomic status almost always reduces, though
seldom eliminates, the effects of race and ethnicity on the health care
that a patient receives (IOM, 2002b).
I. The National Healthcare Disparities Report
should present analyses of racial and ethnic
Native; Asian; Black or African American; Native Hawaiian or other Pacific
Islander; and White. OMB Directive 15 defines ethnicity separately from
race, and it is limited to Hispanic or Latino or not Hispanic or Latino.
2 Socioeconomic status is a complex concept that combines dimensions of
social and economic resources as well as societal ranking or prestige.
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EXECUTIVE SUMMARY
disparities in health care in ways that take into
account the effects of socioeconomic status.
3
There are questions about how best to measure the influence
of socioeconomic status on health care. Socioeconomic status is
mainly measured using income and education. However, both have
different meanings for different racial, ethnic, and other populations,
and their use can be problematic when this variation is not taken into
account. Income, for example, more accurately captures the financial
resources of minorities than Whites, who are more likely to have
assets such as real estate and other investments (Oliver and Shapiro,
2001; Smith, 2001~.3 Educational levels for Whites and minorities can
have different implications because minorities often attend schools
with fewer resources and less prestige. Similarly, an immigrant's
degree earned from a school abroad may be valued less than a degree
earned at an American school.
AHRQ should sponsor research on the relationship between
socioeconomic status and health care as a basis upon which to
construct more accurate and meaningful measures. Areas where
research is needed include identification of the dimensions of
socioeconomic status that most influence health care access, service
utilization, and quality, and the reasons for their influence. Research is
also needed to evaluate how well measures of socioeconomic status
are associated with access, use, and quality of health care services. In
addition to income and education, these measures include but are not
limited to total wealth, occupation, and deprivation indices, that is,
composite measures formulated from such vanables as employment
status and access to a car.
2. A~Q should pursue a research initiative to
more accurately and meaningfully measure
socioeconomic status as it relates to health care
access, service utilization, and quality.
3 For example, in 1994, White households had a median income of $33,600;
Black households, $20,508; and Hispanic households, $22,644. In terms of
net financial assets, White households had a net worth of $7,400; Black
households, $100; and Hispanic households, $300 (Oliver and Shapiro, 2001~.
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4 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
Access to health care is particularly important for racial and
ethnic minorities. They have fewer economic resources and more
frequently live in disadvantaged geographic areas. They are more
likely to report that they are in fair or poor health and are more likely
to receive discnminatory treatment in the health care system. In
addition, they are less likely to get preventive services and attention
for many chronic conditions. They also have higher mortality rates
from a range of conditions (IOM, 200 1a; TOM, 2002b).
Access applies to entry within the system of care as well as
entry to the system of care. While access to the system of care may
mean that a patient gets emergency or primary care, access within the
system of care is necessary to obtain such vital services as specialized
care, prescription drugs, and follow-up treatment. Access to and within
the system of care is influenced by such diverse factors as insurance
coverage, the availability of transportation, language translation
services and other aspects of cultural competency, and time that can be
taken from work.
3. Access is a central aspect of health care quality.
As such, the National Healthcare Disparities
Report should give it prominent attention.
in general, minorities receive fewer services than advantaged
populations. However, in certain cases, minority populations receive
more services, and they usually indicate poor prior care (LaVeist,
2002~. For example, African Americans with diabetes are more likely
to have limbs amputated than Whites. Including measures of both
kinds of disparities in the NHDR would provide a fuller picture of the
inferior health care quality often experienced by minorities (IOM,
1993~.
4. The National lIealthcare Disparities Report
should include measures of high utilization of
certain health care services that indicate poor
health care quality. It should also include measures
of low utilization of certain health care services,
which are more commonly used to indicate poor
health care quality.
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EXECUTIVE SUMMARY
5
While the NHDR should feature national level data, it should
also include data by smaller geographic units that interest the report's
primary audiences of members of Congress, other policy makers, and
consumers. For example, analyses such as state-by-state comparisons
on health care are familiar and meaningful to members of Congress,
other policy makers, and consumers (IOM, 200Ib). Many members of
Congress also represent rural and urban areas, making them highly
relevant (Ricketts, 20021.
5. The National Healthcare Disparities Report
should present data on disparities at the state level.
It should also present data on disparities along a
rural-urban continuum.
National datasets such as the Medical Expenditure Panel
Survey (MEPS) and the National Health Interview Survey (NHTS)
currently do not have the sample sizes needed to supply data for the
NHDR on geographic disparities by regions or states. Their sample
sizes are also too small to supply data on disparities for such racial and
ethnic subpopulations as Chinese, Korean, and Indian Asian
Americans (Reilly, 2002~.
Subnational data sources hold promise for supporting
measures in the NHDR. Many racial and ethnic subpopulations are
geographically concentrated and well represented in survey samples.
However, they also have a number of limitations. For example,
subnational datasets measure race and ethnicity in different ways.
While some allow respondents to choose more than one racial
category, others do not. In some, race and ethnicity are reported by
respondents, while in others they are reported by observers. AHRQ
should work with public and private organizations that sponsor key
subnationa] data sources to address issues of standardization.
6. In the future, if A~Q continues to rely on
suhnational data sources for the National
Healthcare Disparities Report, it should work with
public and private organizations that sponsor key
suhnational data sources to identify core elements
in surveys that can be standardized.
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6 GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
AHRQ must use measures and datasets that meet rigorous
scientific standards if it is to provide a credible and useful report for
policy makers and other audiences. To do so, AHRQ will need
expertise and substantial means to carry out such tasks as identifying
appropriate ways to measure socioeconomic status in relation to health
care disparities and formulating and evaluating measures of health care
access, service utilization, and quality based on their validity,
reliability, and other criteria. Measures require data to support them.
However, the agency must have access to the expertise and resources
needed to improve the usefulness of subnational datasets to the
NHDR.
7. A~Q should receive adequate resources to
develop ~latasets and measures needed for the
National Healthcare Disparities Report.
The NHDR could benefit from an association with the NHQR.
In addition to the conceptual framework that the reports share,
measurement selection for the NHDR could be guided by the process
used for selecting measures for the NH:QR. Both could feature the
same measures where those in the NHQR have special relevance to
areas where disparities are particularly large, are likely to result in
death or serious illness, or are amenable to improvement. Measures
included in the NHQR will be selected from a larger set of measures
AHRQ will use to monitor health quality. The NHDR could also be
drawn from measures in this larger set if they are more relevant to
disparities. Lastly, the NHDR could make use of measures of
disparities in health care access, utilization, and quality described in
commissioned papers by lLaVeist (LaVeist, 2002) and Lurie (Lurie,
2002).
Conclusion
The National Healthcare Disparities Report could play a major
role in raising awareness of racial, ethnic, socioeconomic, and
geographic health care disparities. It could also help to guide Congress
and other policy makers in areas that require action to eliminate
disparities.
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EXECUTIVE SUMMARY
7
The Committee's guidance on data and measurement
development as well as report content would enhance the contributions
that the NHDR could make to this cntical area of health care. The
Committee's guidelines are summarized in Table ESPY.
TABLE ES-1 Guidance for the National Healthcare Disparities Report
1. The National Heaid~care Disparities Report should present analyses of
racial and ethnic disparities in health care in ways that take into account
the effects of socioeconomic status.
2. AHRQ should pursue a research initiative to more accurately and
meaningfully measure socioeconomic status as it relates to health care
access, service utilization, and quality.
3. Access is a central aspect of health care quality. As such, the National
Healthcare Disparities Report should give it prominent attention.
4. The National Healthcare Disparities Report should include measures of
high utilization of certain health care services that indicate poor health
care quality. It should also include measures of low utilization of certain
health care services, which are more commonly used to indicate poor
health care quality.
5. The National Healthcare Disparities Report should present data on
disparities at the state level. It should also present data on disparities along
a rural-urban continuum.
6. In the future, if AHRQ continues to rely on subnational data sources for
the National Healthcare Disparities Report, it should work with public and
private organizations that sponsor key subnational data sources to identify
core elements in these surveys that can be standardized.
7. AHRQ should receive adequate resources to develop datasets and
measures needed for the National Healthcare Disparities Report.
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GUIDANCE FOR THE NATIONAL HEALTH CARE DISPARITIES REPORT
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EXECUTIVE SUMMARY
9
Lurie, N. 2002. Measuring disparities in access to care. In Guidance for the
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Representative terms from entire chapter:
national healthcare
