A Robert Wood Johnson Foundation Program to Evaluate Interventions to Reduce Health Care Disparities

Abstract

The Robert Wood Johnson Foundation Finding Answers: Disparities Research for Change program funds evaluation of interventions to reduce racial and ethnic disparities in cardiovascular disease, depression and diabetes. Of the 177 applications received in 2006, the most prevalent proposed interventions were patient or provider education (57%), case management (24%), integrated health care (24%), community health workers (25%), and cultural modification (24%). Policy interventions, including incentives such as pay-for-performance, were lacking. The 11 grantees target patients, providers, patient-provider communication, health care organizations, and communities in innovative ways. We identify important future research questions.

Eliminating health disparities is a national priority. Unfortunately, research has been slow to progress from documenting such disparities to designing, implementing and disseminating interventions to narrow these differences. Consequently, the Robert Wood Johnson Foundation (RWJF) created a national program, Finding Answers: Disparities Research for Change in 2005.¹ The RWJF is committed to ensuring that all Americans receive quality health care. Through its funding, RWJF aims to help communities across the county set and achieve ambitious goals to improve the quality of health care in ways that matter to patients and their families, particularly patients from specific racial and ethnic backgrounds who often experience lower-quality care.

Among other goals, Finding Answers is charged with providing grants to fund evaluation of health care interventions across the country that hold promise to reduce racial and ethnic health care disparities and improve health care quality for minority patients in one or more of the following diseases: cardiovascular disease (CVD), depression and diabetes. These diseases were chosen because they affect large numbers of patients, they cause significant morbidity and mortality, and evidence-based standards of care exist.

The Finding Answers program is discovering knowledge that has several policy implications. Foremost, Finding Answers is identifying replicable solutions to reduce racial and ethnic health care disparities in the context of health delivery systems in the United States. This evidence base will assist shaping policies that facilitate disparities reduction by noting what does and does not work, how to work with and modify the current health care infrastructure to implement effective interventions, and institutional challenges to enacting such changes.

Based upon the 177 eligible applicants for Finding Answers’ first Call for Proposals (CFP), this paper provides an overview of what some organizations responsible for the provision of health care view as the current practices and interventions with potential to address and decrease disparities in challenging real-world environments. These organizations reflect the applicants to one funding program, although other such programs exist. We also describe the 11 successful applicants and outline key research questions for reducing disparities.

Methods

The CFP aimed to identify innovative replicable interventions through a two stage proposal process. Eligible organizations were those that provided interventions within a consistent source of health care. Finding Answers funds were designated for evaluating the intervention, gathering process information on implementation, and performing cost analyses. Thus, eligible proposals included those with existing interventions or ones ready for implementation by December 2006. Applicants were encouraged to submit a five-page brief proposal during January-March 2006. Of the 177 eligible brief proposals, the National Program Office and RWJF selected thirty-eight to submit twenty-page full proposals. After receipt of thirty-six full proposals, the National Advisory Committee selected sixteen for site visits, and recommended grant awards to eleven. RWJF approved all selections and recommendations.

All 177 proposals were reviewed and analyzed both quantitatively and qualitatively to determine what types of interventions were proposed to eliminate health care disparities. The data extraction and coding scheme for the analysis were based on six target domains of the conceptual model for racial and ethic disparities in health care proposed by Chin et al: organization, patient, provider, patient-provider communication, community, and policy.²

Results

Disease Focus

Proposals most frequently targeted diabetes disparities (40%), followed by depression (15%) and CVD + diabetes (15%), while CVD + depression received the least (<1%).

Race/Ethnicity

Across all proposals, African-Americans and Hispanics/Latinos were included among the target populations the most (71% each). African-Americans were exclusively targeted in 23% of these proposals, while Hispanics/Latinos were exclusively targeted in 25%. Proposals that included American Indians in the target populations were the least prevalent (16%) and were more likely to include American Indians exclusively.

Age and Gender

The majority of proposals were directed toward adults (≥ 18 years) with few targeting solely children less than 18 years (4%) or geriatric populations 65 years or older (2%).

Location and Organization Setting

The majority of proposals were set in urban areas (58%). Overall, the most common settings for the interventions were community health centers (33%), hospitals (20%), and primary care clinics (18%).

Intervention type

Individual proposals ranged from having zero to 13 different intervention types, with a mean of 4 types.

Target Domain of Intervention

Organization

Interventions targeting the organizational level were common across disease foci in all proposals. The most common intervention categories fitting in this conceptual model component included screening (27%), case management (24%), and integrated health care (24%).

Patient

The most common interventions targeting the patient level were patient education (55%) and culturally tailored interventions (24%).

Provider

Overall, the most common intervention categories fitting into the provider component were provider education (30%) and audit and feedback (10%).

Patient-Provider Communication

Interventions targeted improved patient-provider communication (20%) and interpreter services (2%). Patient-provider communication interventions were most common in diabetes proposals (31%).

Community

The most common intervention linking the community with the health care delivery system was use of community health workers (25% of total), most frequently in diabetes proposals (34%).

Policy

Examples of policy interventions in the CFP were programs related to pay-for-performance and public reporting. Given that the Finding Answers program provides funds for health care delivery organizations and health plans, broad legislative policies were beyond the scope of this program. Interventions targeting policy were the least common across all proposals. Public reporting of performance data was present in 6% of all proposals, while pay-for-performance tied to service provision or health outcomes was a component in 3%.

Grantees

Of the 177 brief proposals, Finding Answers awarded more than $2 million to the 11 organizations described below. As a group, the 11 successful proposals had diverse locations and populations throughout the United States, had active support from all participants, strong academic-community partnerships, outlined rigorous evaluations of their interventions, and had promise as practical, replicable solutions. Interventions targeted the organization, patient, provider, patient-provider communication, and community domains. Round 1 funding began December 2006 and will end December 2008, thus evaluation results are forthcoming. Future rounds of funding will add to the knowledge gained.

Targeting Primarily Patient Domain

Choctaw Nation Health Services Authority, Oklahoma

This organization is evaluating the use of tribal Diabetes Educators and Community Health Representatives to elicit patients’ cultural perceptions of diabetes and diabetes treatments with the goal of improving patient-provider communication.

Cooper Green Hospital, Alabama

Cooper Green Hospital is evaluating a novel interactive DVD promoting hypertension management and patient-provider communication for African-American patients through peer storytelling.

Massachusetts League of Community Health Centers, Massachusetts

This two-phase project offers a robust evaluation of community health workers (CHW). The first phase of Massachusetts League of Community Health Centers’ project focused on training and providing support to 17 health centers implementing a rapid cycle system redesign for patients with diabetes. The second phase provides deployment of CHWs with advanced ongoing training to reduce health care disparities in low income, ethnically diverse health center populations.

University of California-Irvine, California

University of California-Irvine is evaluating the Coached Care for Diabetes Program to improve the care of Latinos and Asian/Pacific Islanders with type 2 diabetes. The Program uses coaches from the community with type 2 diabetes to provide individualized treatment information and to help patients negotiate a treatment that is in-line with their preferences, culture, and lifestyle with the goal of preparing patients to take a more active role in their health care.

Targeting Primarily Provider Domain

Harvard Vanguard Medical Associates, Massachusetts

Harvard Vanguard Medical Associates is evaluating an enhanced Chronic Care Model program which includes a bimonthly panel-level disparities report card, training in assisting patients with navigating the health care system, and cultural competency training. This program targets providers to improve the care of African-American patients with diabetes.

Morehouse School of Medicine, Georgia

Morehouse is evaluating a quality improvement program that adjusts care of hypertension based on an assessment of patients’ health literacy which is incorporated directly into the patient’s electronic health record.

Westside Health Services, Inc., New York

Westside Health Services is evaluating a concurrent peer review program that uses a clinical peer of the patient’s provider to review the patient’s diagnostic and treatment plans. Program goals include improving the quality of diabetes and hypertension care provided to the patient by providing a fresh look that reduces clinical inertia resulting partly from competing demands on the primary clinician’s time.

Targeting Primarily Organization Domain

Neighborhood Health Plan of Rhode Island, Rhode Island

Neighborhood Health Plan of Rhode Island is evaluating how a culturally appropriate, 12 week telephone-based depression care management program for Latinos compares to usual depression care in geographically dispersed health centers in a Medicaid health plan.

Olive View-UCLA-Drew, California

Olive View-UCLA-Drew is evaluating a clinic-based program involving depression screening during patient intake, provider reminders, use of treatment algorithms, an electronic patient registry, post-visit counseling by a nurse, and patient education to improve the quality of depression care for African-American and Latino patients.

University of Southern California, California

University of Southern California is evaluating the use of promotoras combined with a culturally appropriate social worker to screen for depression, and improve access to and utilization of care for low income minority populations in a unique setting. Patient screening will occur in the emergency department, which is being disproportionately used by the target population for health care services. Patients who screen positive will be offered brief psychotherapy with the social worker, medication from a psychiatrist, or both.

Yale University School of Medicine, Connecticut

Yale is evaluating a screening program for depression in inner city women in a pediatric primary care setting. Detection of behavioral problems in children identifies mothers at risk for depression who are then formally screened. Women who screen positive for depression will receive on-site cognitive behavior therapy or intensive case management.

Discussion

There is growing momentum to discover promising interventions to reduce health disparities in cardiovascular disease, depression, and diabetes. The most commonly proposed interventions to the Finding Answers program were organization-level and patient-level projects targeting urban African-Americans and/or Hispanic/Latino populations. Specifically, case management, integrated health care, culturally-tailored interventions, community health workers, and patient and provider education were most prevalent.

These results are generally consistent with our recent reviews of the literature that identify multi-component interventions targeting different leverage points, nurse-led case management in the context of wider systems change, culturally-tailored quality improvement, and community health workers as showing promise.³ Given the overall paucity of interventions that address disparities, additional research in areas of promise is needed. Specifically, if racial and ethnic disparities in health care are to be reduced or eliminated on a broad scale, successful interventions need to be disseminated and replicated in a variety of populations and settings across the nation.

Our prior systematic reviews suggest that it will be important to simultaneously target both institutions serving large numbers of minority patients and institutions serving both white and minority populations.⁴ Recent studies indicate that an important driver of disparities is where patients receive their care.⁵ Underfinanced facilities could benefit from more resources and quality improvement interventions, while well-financed institutions serving both white and minority populations and institutions serving large numbers of minority populations may benefit from culturally tailored care. Our prior literature reviews found that culturally tailored programs probably are more effective than generic quality-improvement interventions. Interestingly, significant percentages of our applicants included cultural tailoring and community health workers in their proposals.⁶ For example, the Harvard Vanguard intervention uses disparity report cards to demonstrate racial and ethnic disparities in quality of care within an individual provider’s panel of patients, and then provides cultural competency training and patient-centered health navigation to reduce these differences in care. Nationally, we will need to address both disparities across institutions and those within institutions with resources and culturally tailored interventions.

Several challenges exist pertaining to the dissemination and replication process. These challenges include:

1. Determining what parts of multi-component interventions provide the most value. Single bullet interventions are becoming rare since they generally are less effective than systems change.

2. Tailoring interventions to target populations and organizations. We need to try many more interventions across a variety of patient populations and settings.

3. Understanding how to best implement interventions to reduce racial and ethnic disparities in care. Quality improvement implementation research is a nascent field and information on how to implement disparities interventions is particularly scant.

4. Integrating the strengths of the community and health care systems. Too often the community and health care system have remained separate worlds, and relatively few people have been trained to integrate them. The fact that 25% of Finding Answers’ applicants proposed community health worker interventions indicates the enthusiasm some front-line organizations have for such integrative solutions. Interventions incorporating the strengths of social networks show promise, including African-American churches and a variety of community-based organizations.

5. Reducing disparities in understudied populations such as American Indian and Asian-American subgroups, and pediatric and geriatric ethnic subgroups. Adult African-American and Latino populations have been the subjects of most disparities intervention research.

6. Determining the most cost-effective and financially feasible interventions to reduce disparities from the perspectives of society and the business manager. Ultimately interventions will need to be both cost-effective to society and financially logical from the perspective of the business manager to be worthwhile and sustainable. Cost analyses in the disparities intervention field are rare.

7. Analyzing the effect of policies linking quality to payment and other performance incentives on disparities. Given the national interest in pay-for-performance programs, little is known about their impact on racial and ethnic disparities as equity issues have not been a prime consideration for many organizations implementing pay-for-performance programs.⁷ Key program design issues would be greatly informed by such research. For example, should relative improvement in quality be rewarded in addition to absolute levels of quality, and what can be done to deter cherry picking of simple patients and dumping of difficult patients?

Often, the dissemination of promising interventions is slow given that little guidance on the above challenges is provided. Ultimately, the goal of the Finding Answers program is to not only determine what interventions are successful in reducing racial and ethnic disparities, but also to elucidate how one implements those successful interventions. For this reason program grantees are including analysis of the implementation process and providing contextual data. Grantees are also supplying cost information and developing tools to help others seeking to replicate the intervention in their own setting to reduce disparities.

Several of the aforementioned gaps in the literature were not addressed by significant numbers of proposals. Literature addressing policy interventions such as pay-for-performance or public reporting of performance data is lacking. A recent review by Chien et al. found only one study examining how health disparities are impacted by use of monetary and reputation-based performance incentives programs and only 3% of the brief proposals involved any incentives component.⁸ Nurse-led or other non-physician provider-led interventions have also shown promise in the literature, particularly in case management interventions.⁹ However, very few proposals focused on using non-physician providers.

Other understudied areas in the literature that are consistent with few numbers of proposals include involvement of geriatric, pediatric, American Indian and Asian-American target populations. The lack of literature on interventions in the geriatric population is troubling since many older persons have the three target conditions, the aging of the Baby Boom population is increasing disease prevalence further, and older persons have special needs, challenges, and issues that probably make tailoring of interventions worthwhile. Moreover, the growing interest in quality improvement and disparities reduction in the Medicare population focuses primarily upon the geriatric population, and thus evidence-based interventions to reduce disparities in this group are urgently needed. The second CFP included language to encourage proposals targeting pay-for-performance, public reporting, and nurse-led interventions to address these gaps from Round One.

Our study has several limitations. First, proposals were limited in length so detailed descriptions of intervention types were not possible, and applicants sometimes used non-specific or general terms to describe their interventions. This lack of detail may have led to over-generalization of intervention types. In addition, data come from one national grants program of one funder, limiting generalizability. Nonetheless, the Finding Answers program was one of the major Calls for Proposal in a difficult funding environment.

We need to move beyond documenting racial and ethnic disparities in health care to finding solutions to eliminate these differences. The Robert Wood Johnson Foundation Finding Answers Program aims to move the research process along this continuum to discover practical, real-world interventions that reduce disparities.