1. Finding Answers: Disparities Research For Change Jeroan J. Allison, MD, MS Special Editor June 5, 2007 Academy Health

2. Presentation Overview Summary of findings Additional relevant material Discussion questions

3. Change in Core Quality: 2006 AHRQ National Health Disparities Report C

4. Effective Interventions Diabetes –Organizational restructuring –Expanding role of nurse in chronic disease management context Incentives (P4P, public reporting) –Effect on disparities remains an empiric question –Potential for disparity reduction –Potential exacerbation for careless implementation Community Interventions –Enormous potential –Barriers underestimated

5. Culturally Leveraged Interventions Domains –Individual health behaviors –Access to care –Health-care environment Findings –Significant promise –Highly variable response –Nescient field Fisher T, Burnet D, Huang E, Chin M, Cagney K. Cultural Leverage: Interventions Utilizing Culture to Narrow Racial Disparities in Health Care. Medical Care Research and Review. In Press.

6. Culturally Leveraged Interventions: Individual Health Behavior These interventions showed promise in improving health; however, a limited number actually assessed health outcomes and when they did, the demonstrated effect was not robust.

7. Culturally Leveraged Interventions: Access to Care As a group, access interventions were creative in using culture to improve the health care of people of color; however they struggled to show significant improvements.

8. Culturally Leveraged Interventions: Health-care Environment As a group, these interventions were the most heterogeneous in approach and outcome assessment.

9. Residential Segregation: Beyond Patient, Provider, and System Interventions Fundamental versus proximate cause of health disparities Consequences –Neighborhood safety –Housing adequacy –Health promoting infrastructure –Education –Income Williams D, Collins C. Public Health Reports. 2001; 116(5): 404-416

10. Inattention to eliminating residential segregation and/or the conditions created by it may limit the utility of well-intentioned efforts to reduce racial disparities in health. Williams D, Collins C. Public Health Reports. 2001; 116(5): 404-416

11. Take Home Messages Health disparities remain an important problem Complex interactions –Race/ethnicity –Socioeconomic position –Health care system –Environment Potentially effective interventions –Spectrum illustrated by current review –No easy formula –Significant variation by condition and setting

12. Conceptual Model Provider Patient Financing / Regulation / Accreditation / Quality Improvement Health Care Organization Person Community Process Outcomes Access Chin M. Walters A, Cook S, Huang E. Interventions to Reduce Racial and Ethnic Disparities in Health Care. Medical Care Research and Review. In Press.

13. Discussion Questions Is there a tension between improving health for all versus specific population segments? Have we been too enthusiastic about certain approaches? –Community interventions –Culturally leveraged interventions?

14. Discussion Questions How may we improve the approach to community health worker interventions, given the recognized emerging barriers? How may pay-for-performance and public reporting be best configured to decrease health disparities?

15. Discussion Questions How well do we understand the basic mechanism leading to disparities in health outcomes? How will current intervention strategies translate to patients with complex co- morbidity?

16. Discussion Questions What areas/approaches will allow the most return on investment for reducing disparities? For funding agencies? For policy makers? What efforts are needed to move beyond the patient, provider, and system interventions discussed today?

18. Extra Questions Is there a tension between developing interventions at multiple levels, such as community, patient, provider, and system? Why do culturally leveraged approaches appear to work under some circumstances and not others?