What Has Justice to Do with Medical Quality and Safety? Care, Cultural Diversity, and the Vulnerable among Us



In 2007, the U.S. Agency for Healthcare Research and Policy (AHRQ) reported that not only do significant disparities in healthcare quality exist between whites and minorities, but that these disparities have not been reduced in recent years.[1] In fact, 60% of the clearly documented disparities did not decrease significantly on follow up. The metrics applied were comprehensive in that 42 measures of quality and 8 measures of access to care were evaluated. For example, the number of extremity amputations for diabetics, the adequacy of dialysis, and the incidence of AIDS were all associated with lower quality outcomes for certain minority groups (African Americans, Asians, and Hispanics were included in the analyses). Quality metrics are also a reflection of how many medical errors, adverse events, and complications culturally diverse persons incur while they are treated. As a natural corollary of the 2007 AHRQ report, a June 2008 brief from the AHRQ probes a more pervasive problem.[2] The investigators found, not surprisingly, that there are also racial and ethnic disparities in hospital safety statistics. Bottom line, minorities are the victims not only of lower quality care, but also of care that is unsafe.

If a “Root Cause Analysis” is performed, what are the reasons ethnic minorities receive lower quality care? Let’s start by pursuing a specific instance. All three minority groups—African-American, Asian, and Hispanic—had a 21 to 34% higher complication rate than whites for postoperative metabolic complications and a 14 to 21% higher rate for postoperative respiratory failure. It seems that minority postoperative care is globally deficient based on quality and safety outcomes because hemorrhage and sepsis incidence were also increased after surgery in some of these ethnically diverse groups. Although explicit risks and explanations are not provided to accompany the raw data, it would not be presumptuous to blame access to care and specific supply side issues relevant to the current healthcare reform debate. The differences in morbidity and mortality data when elective surgery becomes emergent is known. When timely access and the financial means for healthcare are not available, it is natural for people to delay intervention until they have no other recourse, at which point advanced and irreversible pathology is the rule, not the exception.

Regarding the supply side problem, the recent Dartmouth Atlas has reframed another disturbing inequity in healthcare that may be operative here.[3] Regions in the U.S that are populated by a greater density of specialists and acute care hospital beds spend more money for healthcare. This pattern suggests that overabundant supply creates demand for procedures and the result is multiple consultants who are reimbursed for services that may not all be necessary. In these instances, reimbursement comes from Medicare during the last 6 months of life. That supply side model is driven by fee for service only for those who have the means, rather than by service, quality, and safety for those outside the pale of insurance or egregious co-pays.

Culturally diverse populations do not have just access to the “supply” of specialists. The reasons why are clear. As a last resort, the disadvantaged access “safety net” hospitals too late, and are prone to lower quality and less safe care as a direct result. A two-tiered system is in place. Decreased and delayed access for the un- or underinsured and an oversupply, at least in some regions, of expensive and possibly unnecessary care inappropriately driven by generous reimbursement highlight a glaring human need.

Healthcare reform is long overdue. Although the vulnerable come from all walks of life and represent all “colors,” again the culturally diverse are bearing a disproportionate burden of the healthcare crisis.



[1] National Healthcare Disparities Report, 2007. U.S. Agency for Healthcare Research and Quality. http://www.ahrq.gov/qual/grdr07.htm accessed June 11, 2008.

[2] Russo CA, Andrews RM, Barrett M. Racial and Ethnic Disparities in Hospital Patient Safety Events, 2005. Healthcare Cost and Utilization Project, Agency for Healthcare Research and quality, Statistical Brief #53, June 2008.

[3] The Care of Patients with Severe Chronic Illness: A report on the Medicare Program by the Dartmouth Atlas Project. The Dartmouth Atlas of Healthcare, 2006.


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