In their coverage of AHRQ’s latest annual quality and disparities reports (Quality PDF | Disparities PDF), most outlets focused on disheartening news on health-care-associated infections, but the disparities report also deserves a second look. It’s 302 pages that can be oversimplified as “disparities still exist, they’re not getting better, and they’re worse in some areas than in others.”
Here are a few of the more interesting bullet points, all pulled from the first 16 pages of summary information.
- For Blacks, Asians, and Hispanics, at least two-thirds of measures of quality of care are not improving (gap either stayed the same or increased).
- For Blacks, only about 20% of measures of disparities in quality of care improved (gap decreased).
- For poor people, disparities are improving for almost half of the quality measures.
- The largest disparities for Blacks, AI/ANs, and Hispanics included the rate of new AIDS cases. The rate for Blacks was almost 10 times as high as the rate for Whites, for Hispanics more than 3 times as high, and for AI/ANs 1.4 times as high.
- Asians were 1.5 times as likely as Whites to report they sometimes or never get care for illness or injury as soon as wanted. Poor people were more than twice as likely as high-income people to report this
problem. - Hispanics were 1.7 times as likely as Whites and poor people were 3 times as likely as high-income people to report poor provider-patient communication.
- 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 and in
commended hospital care for pneumonia. - Blacks and Hispanics both had worsening disparities in colorectal cancer mortality from 2000 to 2006.
The report doesn’t stop with bullet points, of course. Anyone who takes a few minutes to page through the other 280-some-odd pages will be rewarded with in-depth information on disparities in a number of specific diseases and issues – including breast cancer, diabetes, HIV, palliative care, mental health and access to health care – all buttressed with charts, graphs, explanations and data.
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A fundamental problem with standard appraisals of changes in health and healthcare disparities is the failure to recognize the way differences between rates tend to be affected by the overall prevalence of an outcome. Most notably, the rarer an outcome the greater tends to be the relative difference in experiencing it and the smaller tends to be the relative difference in avoiding it. Thus, as mortality declines, relative differences in mortality tend to increase while relative differences in survival tend to decrease. As beneficial procedure rates increase, relative differences in receipt of those procedures tend to decrease, while relative differences in failing to receive them tend to increase. But neither declining disparities in one outcome nor increasing disparities in the opposite outcome can alone provide useful information on whether disparities are decreasing or increasing in a meaningful sense. The National Healthcare Disparities Report shows no recognition of these issues. Thus, the report’s conclusions about changes in disparities are invariably suspect.
See my presentation “Measurement Problems in the National Healthcare Disparities Report,” American Public Health Association 135th Annual Meeting & Exposition, Washington, DC, Nov. 3-7, 2007:
http://www.jpscanlan.com/images/APHA_2007_Presentation.ppt; http://www.jpscanlan.com/images/ORAL_ANNOTATED.pdf; http://www.jpscanlan.com/images/Addendum.pdf
See the following comment on a 2008 Pediatrics study where the authors, relying on relative differences in vaccination rate as a measure of disparity, found that a school-entry Hepatitis B vaccination requirement dramatically reduced racial and ethnic disparities in vaccination rates; the National Center for Health Statistics, which would have relied on relative differences in failure to be vaccinated, would have found dramatic increases in disparities.
http://pediatrics.aappublications.org/cgi/eletters/121/3/e547
See also the Measuring Health Disparities, Scanlan’s Rule, and Mortality and Survival pages of jpscanlan.com.