On the road to reducing health disparities: evidence-based solutions

A new program of the Robert Wood Johnson Foundation based at the University of Chicago seeks evidence-based solutions to reduce major disparities that exist along racial and ethnic lines in the United States for a variety of medical conditions.

Described as a "roadmap," the program includes six papers published July 24 in the Journal of General Internal Medicine and builds upon seven years of work administering grants, reviewing literature, and providing technical assistance to reduce health disparities. The content encompasses systematic reviews of disparities interventions in HIV, colorectal cancer, cervical cancer, prostate cancer and asthma.

Titled Finding Answers: Disparities Research for Change, the roadmap aims to give organizations expert guidance on what they can do to improve health equity in their own patient populations. The roadmap's architects hope that it can provide direction for effective and sustainable interventions as the health disparities field shifts from measuring the problem to taking action.

"Often when you say the challenge is to reduce disparities, people feel overwhelmed. It's a big challenge," said Marshall Chin, MD, director of Finding Answers and Richard Parrillo Family Professor of Medicine at the University of Chicago Medicine. "But the roadmap provides order so that people can avoid missing what's necessary to create the change."

The paper highlights the initial need for recognizing disparities and committing to their reduction, and suggests that programs to reduce disparities should be integrated into broader quality improvement efforts at clinics, hospitals and other health systems.

"In the past, people did disparities work or quality work but the two wouldn't touch one another," Chin said. "We're merging the quality improvement field and the disparities field."

Across the five new articles and previously published reviews of cardiovascular disease, diabetes, depression and breast cancer, researchers identified characteristics of successful interventions. Effective projects were found to utilize team care, patient navigation, cultural tailoring, collaboration with non-healthcare partners such as families or community members, and interactive skill-based training.

The reviews also identified potential targets for reducing health disparities that have not yet been examined. For example, in colorectal cancer, reviewers found that projects concentrated entirely on improving minority screening rates, with no efforts focused on post-screening follow-up or adherence to treatment. Many interventions also exclusively targeted patient knowledge and behavior to reduce disparities, instead of looking at other components of the healthcare system.

"Most interventions have been focused on the patient, essentially asking the patient to change rather than looking at the people who are serving the patient and saying what can we change with that system," said Amanda Clarke, MPH, project manager for Finding Answers and co-author of the roadmap paper. "There's opportunity to do more research and more interventions that are targeting the organization, the immediate care team, and how the team dynamics work."

While offering general guidelines for best practices, the authors point out that the specifics of any effort to reduce disparities must be custom-fit to the patient population and community that an organization seeks to help.

"What may work in one setting may not work in another," said Scott Cook, PhD, deputy director of Finding Answers and a co-author on the paper. "We thought the roadmap would…provide guidance and some sort of guardrails on the side of the road to keep people from going way off the path and losing track of addressing disparities in a way that will work."

The roadmap also emphasizes the need to continually evaluate whether a particular intervention is working, making adjustments as needed. Organizations -- and policy-makers -- should also consider the financial sustainability of efforts to reduce disparities, and should be mindful of unintended consequences for disparities as healthcare reforms are implemented, according to the authors.

"You need to have the financial mechanisms in place to make these efforts sustainable," Chin said. "You can have a very motivated health care organization that knows what to do to reduce disparities, but if in the long run the organization can't afford to support that work, then it's going to be really hard for the work to be done. From a policy perspective, you need to put in place the incentives so people are able to do the right thing -- what they want to do, and what they know will work to reduce disparities."