|Improving health care quality for racial/ethnic minorities: a systematic review of the best evidence regarding provider and organization interventions
|Beach M C, Gary T L, Price E G, Robinson K, Gozu A, Palacio A, Smarth C, Jenckes M, Feuerstein C, Bass E B, Powe N R, Cooper L A
The review evaluated interventions targeted at health care providers to improve health care quality or reduce disparities for racial/ethnic minorities. The authors concluded there are several strategies that may improve health care quality for minorities, but a lack of studies targeting disease areas and processes of care with documented disparities; further research and funding is needed. Overall, the conclusions appear reliable.
To evaluate interventions targeted at health care providers to improve health care quality or to reduce disparities in care for racial/ethnic minorities.
MEDLINE, EMBASE, CINAHL, the Cochrane CENTRAL Register, the Cochrane EPOC Register of trials and the Research and Development Resource Base in Continuing Medical Education were searched from 1980 to February 2003 for studies published in the English language; the search terms were reported. In addition, the table of contents from February 2003 to June 2003 of journals that provided the largest number of citations in the electronic searches and reference lists of included studies and key review articles were screened. Studies published in abstract form were excluded.
Study designs of evaluations included in the review
Randomised or concurrent controlled trials were eligible for inclusion in the review.
Specific interventions included in the review
Studies of interventions targeted at U.S. health care providers or organisations to improve health care quality or to reduce disparities in care for racial/ethnic minorities were eligible for inclusion. The interventions in the included studies were mainly prevention studies, most commonly in the areas of breast and cervical cancer screening. All studies targeted the provider but in some cases there was an additional intervention aimed at the patients. The interventions were, in the majority, a tracking/reminder system. Other interventions were provider education; bypassing the physician using nurse or nurse practitioners to offer standardised services directly to the patients; provision of a structured patient questionnaire to facilitate patient-provider communication about patient health behaviours; use of remote simultaneous translations (translator was not in the same room); use of subspecialty consultation; and use of defibrillators on emergency medical vehicles. Several studies used a combination of these interventions. The majority of interventions did not directly target racial/ethnic minorities.
Participants included in the review
Studies with at least 50% of the patient population belonging to a minority or studies providing a respective subgroup analysis were eligible. Minority was defined as all non-Caucasian or non-white racial and ethnic categories, including African American, Hispanic, American Indian/Alaskan Native and Asian/Pacific Islander. In the included studies, most studies had more than 50% African American patients, a few had more than 50% of Hispanic patients, and the rest had diverse groups with no dominant populations. All studies of interventions were conducted in the out-patient setting. The targeted health care providers were physicians in the majority of studies; in some studies they were physicians and non-physicians, and in very few cases non-physicians only.
Outcomes assessed in the review
Evaluations of interventions were eligible for inclusion; no further inclusion criteria for the outcomes were formulated. The included studies assessed service use, appropriateness of care, quality of providers, patient adherence, efficacy of treatment, patient health status and patient ratings of care. A variety of outcome measures was used.
How were decisions on the relevance of primary studies made?
Two reviewers independently screened the studies and any disagreements were resolved by adjudication.
Assessment of study quality
One reviewer assessed the methodological rigour in the areas of representativeness (e.g. providers clearly described), bias or confounding (e.g. adequate comparison group), intervention description (e.g. allowing replication), outcome assessment (e.g. blinding) and analysis (e.g. complete statistical analysis), and a second reviewer checked the assessment. Any discrepancies were resolved by adjudication or by consultation with the review team. The existing evidence was graded for different intervention categories (grade A to D depending on the quality, quantity and consistency of studies) and an overall score was given.
One reviewer extracted the data using a piloted, standardised form and a second reviewer checked the extraction. Any discrepancies were resolved by adjudication. The data were summarised by identifying the main intervention strategy. The outcomes were categorised using the described outcome areas. Further details of the extracted results (tables) were published online.
Methods of synthesis
How were the studies combined?
The studies were combined in a narrative, separately for interventions to improve the quality of health care for minorities, interventions to reduce disparities, and the costs of quality improvement for racial/ethnic minorities.
How were differences between studies investigated?
Interventions to improve the quality of health care for minorities were synthesised within the following intervention categories: tracking/reminder systems, multifaceted interventions, bypass of physician, provider education, use of safe times questionnaire, use of specialty consultation and use of defibrillators on emergency medical services; no other investigation of heterogeneity was performed.
Results of the review
Twenty-seven studies (n>125,980, exact number unclear) were included: 20 randomised controlled trials (RCTs; n>116,045, exact number unclear) and 7 concurrent controlled trials (n>9,935, exact number unclear).
Randomisation was considered adequate in 41% of the studies. Only 67% of the studies used blinded outcome assessment, and only 48% of studies reported pre- and post-test results. The health care providers were clearly described in 74% of studies, 89% described the intervention so that replication would be possible, and 89% reported complete statistical analyses.
Interventions to improve the quality of health care for minorities.
Ten studies evaluated a tracking and/or reminder system and all demonstrated positive results, mainly in the appropriateness of care. The evidence base was graded as good (evidence grade A). Nine studies reported on multifaceted interventions and these showed mixed results, with most studies reporting improvements in selected but not all outcome measures (evidence grade C).
Two studies bypassed the physician and had either a nurse or nurse practitioner offer screening directly to patients. Both studies demonstrated improvements in the provision of services to patients (grade C).
Two studies investigated provider education and both found improvements in provider counselling behaviours. However, the one study that also assessed effects on the patients did not report positive changes due to the intervention (e.g. such as parental adherence to the provider advice; grade C).
One study used a questionnaire to assess adolescent health behaviours, which was fed back to the providers and demonstrated a positive impact on provider counselling behaviour (grade D).
One study investigated the accuracy of translation and quality of patient-physician communication by using remote simultaneous and proximate consecutive interpretation. This found fewer translation errors and enhanced patient and physician satisfaction by using the remote simultaneous translation method (poor evidence base, grade D).
One study evaluated the use of nephrology consults and found no effect on the health care process or patient outcomes for patients with chronic kidney disease (poor evidence base, grade D).
One study investigated the use of defibrillators on emergency medical services and found no effect on patient outcomes (poor evidence base, grade D).
Interventions to reduce disparities.
One of the multifaceted studies evaluated the impact of two, different, culturally tailored depression interventions to reduce disparities. This showed mixed results: no differential effect on the health care process; improvements in remissions for African-American and Latino patients with no improvement for white patients; and improvement in employment rates for white people but not the other groups. The evidence base in this area was classified as poor (evidence grade D).
One study reported the cost of an intervention (case management and nephrology consultation for patients with chronic renal insufficiency): a minimum of US$89,355 per year in 1998, $484 per intervention patient, and the lack of health benefits for participants.
There are several promising strategies that may improve health care quality for racial/ethnic minorities, but a lack of studies that specifically target disease areas and processes of care for which disparities have been previously documented.
This was a review with a complex question; most inclusion criteria were clearly specified which made the review process transparent despite the complexity. The search was restricted to English language publications which, nonetheless, seemed appropriate given that only studies applicable to the U.S. context were part of the review scope. The review excluded abstract-only studies, a procedure that may have introduced publication bias into the review. Measures were taken throughout the review process to reduce errors and bias. The quality of the included studies was assessed and the reviewers also provided a grading of the evidence.
The included studies varied greatly in terms of the interventions, patient populations, settings, outcome measures and methods of analysis. The narrative synthesis was appropriate and well structured, and concentrated on the dominant intervention. However, it should be kept in mind that most intervention strategies were very complex. The review synthesised a very complex area that may deserve to be investigated in more detail and, overall, the conclusions appear reliable.
Implications of the review for practice and research
Practice: The authors did not state any implications for practice.
Research: The authors stated that more research and more funding are needed. These areas merit further investigation: bypassing the physician to offer standardised services directly to the patients; the use of remote simultaneous translation for patients with limited English proficiency; the use of a structured questionnaire (Safe Times Questionnaire) for health behaviour risk assessment in adolescents; research designed specifically to reduce disparities in health care quality, such as research targeting specific diseases (cardiovascular disease, diabetes, human immunodeficiency virus), and health care processes known to be a source of racial/ethnic disparities; subgroup analyses in studies with diverse populations when generic quality improvement interventions are investigated; and the costs of interventions and quality improvement interventions for American Indians/Alaska Natives or Asians/Pacific Islanders. Furthermore, studies in other than primary care settings, studies measuring patient outcomes with longer follow-up, and studies linking process of care to health outcomes are needed. There is also a need to replicate and evaluate promising intervention methods in different health-care settings and organisations. Multifaceted interventions should be evaluated in a way that enables the identification of the specific piece of the intervention that is most effective.
Agency for Healthcare Research and Quality, contract number 290-02-0018.
Beach M C, Gary T L, Price E G, Robinson K, Gozu A, Palacio A, Smarth C, Jenckes M, Feuerstein C, Bass E B, Powe N R, Cooper L A. Improving health care quality for racial/ethnic minorities: a systematic review of the best evidence regarding provider and organization interventions. BMC Public Health 2006; 6:104
Other publications of related interest
Beach MC, Cooper LA, Robinson KA, Price EG, Gary TL, Jenckes MW, et al. Strategies for improving minority healthcare quality. Evidence Report/Technology Assessment. Rockville (MD): Agency for Healthcare Research and Quality; 2004. Report No.: 90.
Subject indexing assigned by NLM
Continental Population Groups; Ethnic Groups; Evidence-Based Medicine; Health Services Research /methods; Humans; Minority Groups; Outcome and Process Assessment (Health Care); Quality Assurance, Health Care /methods; Socioeconomic Factors
Database entry date
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.