Relatively few quality-improvement efforts have been aimed at reducing differences in children's care and outcomes across race and ethnicity, socioeconomic status, and insurance status. To inform quality-improvement efforts to reduce child health disparities, we summarize lessons learned from the adult disparities-intervention literature, identify interventions that have reduced disparities in pediatric asthma outcomes and immunization rates, and outline special considerations for child disparity interventions. Key recommendations for providers, health care organizations, and researchers include: (1) examine your performance data stratified according to insurance status, race/ethnicity, language, and socioeconomic status; (2) measure and improve childhood health-related quality of life, development, and condition-specific targets (such as asthma and immunizations); (3) measure and improve anticipatory guidance for early prevention of conditions (such as injuries, violence, substance abuse, and sexually transmitted diseases) and efforts to promote positive growth (such as readership programs to improve low literacy); (4) measure and improve structural aspects of care that affect child health outcomes and can reduce disparities, such as patient-centered medical-home elements; (5) incorporate families into interventions; (6) use multidisciplinary teams with close tracking and follow-up of patients; (7) integrate non–health care partners into quality-improvement interventions; and (8) culturally tailor quality improvement. A key recommendation for payers is to align financial incentives to reduce disparities. The National Institutes of Health and other funders should support (1) disparity-intervention studies on these recommendations that analyze clinical outcomes, intervention-implementation processes, and costs, and (2) creation of new child health services researchers who can find effective quality-improvement approaches for reducing disparities.
Equity is one of the Institute of Medicine's 6 pillars of quality health care, along with effectiveness, efficiency, patient-centeredness, safety, and timeliness.1 However, the quality-improvement field has intersected very little with the health care disparities field. Most disparities research has documented differences in care and explored mechanisms that lead to these differences, but comparatively few interventions for reducing disparities have been implemented. In the quality-improvement field, most work has concentrated on improving general effectiveness and safety. Using quality-improvement tools to reduce disparities—that is, making equity an integral component of quality-improvement activities—is a nascent movement.2
As part of the Robert Wood Johnson Foundation's Finding Answers: Disparities Research for Change program, we recently conducted a systematic review of the adult literature on health care interventions that have reduced racial and ethnic disparities in care processes and outcomes. In addition, through our grants program that funds evaluations of disparities-reduction interventions, we have learned about some of the most innovative quality-improvement approaches to reducing racial and ethnic disparities.3 However, although much can be learned from the adult experience, reducing child health care disparities entails special challenges.
In this article, we provide recommendations on health care quality-improvement approaches to reducing child health disparities and identify key areas for future research in this area. We developed these recommendations by (1) reviewing key findings from the adult literature on approaches to reducing racial and ethnic disparities in care and (2) drawing lessons from a review of interventions to reduce racial and ethnic disparities in asthma care and immunizations in children, which are paradigmatic areas for chronic care management and preventive medicine.
We also discuss special considerations for quality-improvement approaches to reducing child health disparities.
LESSONS LEARNED FROM THE ADULT DISPARITIES-INTERVENTION LITERATURE
In this section, we describe 6 integral components of a systems approach for reducing disparities in care. We also provide lessons learned from systematic reviews of the adult literature.
Integral Components of a Systems Approach for Reducing Disparities in Care
In an editorial published in the Annals of Internal Medicine,4 we highlighted 6 necessary components of a systems approach that health care organizations can use to reduce disparities in care.
Examine your own performance data stratified according to insurance status, race or ethnicity, language, and socioeconomic status. Many providers do not believe that disparities exist in their own practices until they see their own objective data. They will not be motivated to work on disparity issues until they are convinced that differences in care exist in their practices.
Obtain training for yourself and your staff in working effectively with diverse populations. Effective disparities-education programs enable providers to examine their own biases and those that their patients bring to the provider-patient encounter. These programs also teach important communication skills such as working with patients who have limited health literacy and individualizing care for the unique medical, sociocultural, and economic contexts in which patients live.5
Make reducing inequities in care for vulnerable populations an integral component of quality-improvement efforts. Some quality-improvement experts believe that a “rising tide lifts all boats,” but evidence suggests that culturally tailored approaches might be more effective than generic approaches.6
Provide the models of care and infrastructure support that organizations need to improve quality of care for vulnerable patients. Many well-meaning health care organizations that wish to reduce disparities do not know where to start. Successful interventions are user-friendly to ensure dissemination and translation, and organizations must provide the environment, process support, and expertise necessary for program uptake.
Align incentives to reward providers and health care organizations for providing high-quality care to vulnerable populations. Ultimately, efforts to reduce disparities must be financially viable to be sustained.
Allocate and advocate for more resources for the uninsured with chronic disease. The uninsured and the safety-net providers who provide the bulk of their care require additional resources. Few incentives exist to care for the uninsured, and many overwhelmed public hospital and clinic systems are in crisis.
Lessons Learned From Systematic Reviews of the Adult Literature
We recently completed a systematic review of the adult racial and ethnic disparities-intervention literature for breast cancer, cardiovascular disease, depression, diabetes, cultural tailoring, and pay-for-performance incentives.6–12 On the basis of this review, we developed the following cross-cutting recommendations: (1) Most successful approaches to eliminating disparities are multifactorial interventions that address multiple leverage points along a patient's care pathway. To improve outcomes, key barriers must be addressed. If a patient cannot overcome any barrier along the pathway of screening, diagnosis, treatment, and follow-up, outcomes will suffer. (2) Culturally tailored quality improvement seems more promising than generic quality-improvement techniques. Culturally tailored approaches, many of which also incorporate generic quality-improvement approaches, tend to address more of the root causes of health care disparities. (3) Promising nurse-led interventions incorporate multidisciplinary teams and close tracking and monitoring of patients. It is unclear why many nurse-led interventions have been successful. However, possible explanations include a heavy emphasis on patient-centered care; multidisciplinary collaborative systems approaches; more time for educating, tracking, and following patients; and a nursing workforce that is more diverse than the physician workforce.
REVIEW OF HEALTH CARE INTERVENTIONS TO REDUCE RACIAL AND ETHNIC DISPARITIES IN CHILDHOOD ASTHMA AND IMMUNIZATIONS
Significant racial and ethnic health disparities have been documented in many areas within pediatric health care. For example, disparities exist with respect to the quantity and quality of anticipatory guidance delivered to parents and adolescents.13–15 Because of the differences between children and adults, we must be cautious about extrapolating lessons from the adult literature to child health disparities. Therefore, we reviewed the literature on quality-improvement intervention studies to reduce child health disparities for 2 representative areas: asthma care and immunizations. Asthma is paradigmatic of a chronic health condition that requires ongoing, coordinated care, and immunizations represent preventive measures.
We searched PubMed and Google Scholar by using the following search terms: “intervention,” “evaluation,” “racial and ethnic,” “minority group,” “pediatric,” “childhood,” “child(ren),” “immunization,” “vaccination,” and “asthma.” We included studies published between 1997 and 2008 that focused on reducing racial and ethnic disparities in care or in which at least 50% of study participants were from racial or ethnic minority backgrounds.
Nineteen studies described quality-improvement interventions to decrease health disparities for pediatric asthma (Table 1). The studies varied in structure, intervention targets, and outcomes. Some studies measured processes of care such as providing an asthma action plan or prescribing inhaled corticosteroids; others measured clinical outcomes such as numbers of symptom-free days, emergency department visits, and hospitalizations. Many of the interventions were multifactorial, which made it difficult in some cases to identify the most important causative factors. Most studies showed positive changes in process or outcome measures, perhaps reflecting publication bias.
In general, studies that targeted clinic operation processes and provider education tended to show improvements in processes of care; a minority of these studies showed changes in clinical outcomes as well. Interventions resulted in significant changes in clinical outcomes when they used case management, social workers, or community health workers or when they targeted patient self-management, family, home environment, specialist clinic referrals, or school settings.
The development of written asthma action or management plans was a component of nearly all interventions that were focused on improving care processes. Overall, these interventions improved the identification of pediatric patients with asthma, increased the number of routine visits for asthma management, and reduced emergency or urgent health care use for asthma.
Improving Care Processes in the Clinical Setting
We now describe specific organizational change and quality improvement, physician or provider prompt, provider-education intervention, specialist referral intervention, care coordination, provider-caretaker communication, and nurse-educator studies. Unless otherwise indicated, each intervention improved clinical care processes.
Four studies included planned organizational change or quality-improvement methods.16–19 One study showed that a large-scale, multisite quality-improvement intervention had no effect.18 The investigators cited the challenges of implementing quality-improvement strategies across multiple sites as a possible factor in the intervention's ineffectiveness.
Two studies included physician or provider prompts to improve the asthma-care process.17–20 These prompts included chart reminders, asthma-visit flow sheets, and clinician pocket guides. Physician or provider education was a component of 4 intervention studies.16–19 The main focus was adherence to the National Asthma Education and Prevention Program guidelines for pediatric asthma care. These studies combined provider education with other components of quality improvement.
Two interventions referred pediatric patients with asthma who frequently used the health care system to specialty care.21,22 Patients in both treatment groups had larger reductions in numbers of emergency department visits and hospitalizations than controls. Four studies focused on improving coordination of asthma care among members of a child's care team.23–26 One study cited the coordinated care model as the theoretical basis for this intervention, which included a robust multidisciplinary intervention.25 Three of these interventions significantly decreased the numbers of emergency department visits and hospitalizations.23–25
Two intervention studies were designed to strengthen communication between providers and caretakers.23,26 Both studies used social workers to counsel families on how to communicate effectively with their child's provider about the child's asthma symptoms. In addition, both studies included asthma education for families.
A nurse educator provided teaching and follow-up with families in 5 studies.22,24,27–29 The investigators of all interventions with a nursing education or outreach component reported a significant reduction in emergency health care usage. Nurse educators stayed in close contact with families, ensured that asthma-management plans were up to date, and adjusted the plans as needed. A successful asthma-management plan intervention also assessed family psychosocial barriers to asthma management and provided problem-solving counseling.27As reported by Weil et al,30 a parent or guardian's mental health problems often decrease their ability to follow asthma-treatment plans for children, resulting in a greater risk for the child of hospitalization for asthma.
Child and Family Education
Twelve intervention studies included an education component on asthma symptom management for children, families, or both.22–26,28,29,31–35 Three studies coupled family education with home environmental assessments or allergen-remediation tools.23,25,34 Three studies evaluated children's computer programs or video games that taught asthma self-management techniques.32,33,35 Two of these studies reported no significant difference between treatment and control groups in the children's asthma self-management skills.33,35
Social Worker and Community Health Worker Home-Visit Interventions
In 3 studies, a clinic social worker or community health worker coordinated asthma-management plans with children's schools.17,25,29 One of these interventions involved a school specifically designed for children with chronic illness and incorporated asthma-medication administration into the school day.29 Children with asthma who were attending the school had less health care system use than controls. Overall, interventions that included a school outreach component demonstrated significantly less health care system use by those in the intervention groups than in the control groups.
Three studies included a home-visitation component with environmental health assessments.17,23,25,34 Homes were inspected for allergens (such as cockroaches or pet dander) to which the children were susceptible. The social or community health worker educated caregivers about techniques to reduce exposures, such as cleaning methods. They provided families with concrete tools to help reduce exposures, such as vacuum cleaners and mattress covers. Providing these materials was important for low-income families, significantly reducing the number of days during which their children had asthma symptoms.23,34 Community outreach workers also improved clinical processes of care by providing information to clinic staff and physicians on the factors that affect families' ability to meet asthma-management goals.17
Reports of 8 studies described quality-improvement interventions to decrease health disparities in pediatric immunizations (Table 2). Many of these studies improved immunization rates, considered here to be a clinical outcome. Some also increased the frequency of well-child visits (considered here to be a process measure).
The main strategies to improve immunization coverage were changes in clinic operation processes (5 studies), outreach to patients' families through telephone calls or mailings (5 studies), community health worker visits (primary intervention in 3 studies, adjunct strategy in 1 study), a collaborative community approach (1 study), and provider incentives (1 study).
Overall, community health worker visits and other outreach methods for families seemed to be most effective in increasing immunization rates. Interventions in the clinic setting showed mixed results that depended on how well the clinic actually implemented the changes. For example, 1 study used provider feedback and incentives to try to improve immunization rates. However, approximately half of the participating practices were unaware of the feedback program, and the investigators could not identify the proportion of providers who actually received incentive payments as a reward for their activities.36 Not surprisingly, this intervention did not yield significant changes in immunization rates.
Reminders for providers and for families were the most common immunization quality-improvement interventions. Fiks et al37 found that building electronic medical record–based alert reminder systems into clinic visits for providers was associated with increased immunization rates. Hillman et al36 examined a provider-assessment and feedback system coupled with financial incentives. The postintervention increase in immunizations was not statistically different between treatment and control groups. Rodewald et al38 found no evidence that physician prompting alone improved immunization coverage. The differences between these study outcomes demonstrate that the method of provider prompting has a significant impact on the likelihood of capturing immunization opportunities, thereby improving immunization rates.
Immunization interventions that included a reminder to parents of children who had not received recommended immunizations showed mixed results. When combined with visits by a lay outreach worker from the same community as the families, reminder approaches increased immunization rates.39 However, mailed-letter and telephone-call reminders were less successful, because many families moved or changed their contact information.40 A crucial component of the family-reminder approach could be removing the barriers to bringing families to the clinic by, for example, reducing wait times41 or providing transportation.39
As in the asthma-intervention literature, lay outreach workers seemed to play an important role in reminding families to ensure that their children's vaccinations were up to date.38,39,42 Interventions that incorporated a community-outreach component increased immunization coverage in low-income, minority children. A community-wide reminder and outreach intervention significantly reduced the disparity in immunization coverage between inner-city and suburban children, as well as between white and minority children.39
LESSONS LEARNED FROM THE CHILDHOOD ASTHMA AND IMMUNIZATION DISPARITIES-INTERVENTION LITERATURE
Pediatric asthma and immunization interventions that include a strong community outreach component are often effective. The factors that make community outreach successful vary according to intervention and between asthma and immunization. Some common components of successful interventions include (1) using lay health outreach workers from the targeted community; (2) conducting home visits to reach families and educate caregivers; and (3) integrating interventions into existing community-based organizations and services such as schools and Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics.
Lay health outreach workers establish effective links between health care clinics and patients in the community. Outreach workers can educate and inform families about their children's health conditions and care and provide coaching to improve communication with their children's health care provider. In addition, outreach workers from the community can inform providers and clinic staff of the daily struggles faced by families in bringing their children in for care. Improved communication between providers and families can increase understanding of each others' abilities, challenges, and strengths.
Interventions that engage community organizations and services strengthen the link between health care clinics and communities. When community organizations help plan interventions and have access to data systems, such as immunization registries, the responsibility for improving the care of a community's children is shared and strengthened between the health care provider and community. Resulting programs are more likely to reflect and meet community interests.
SPECIAL CONSIDERATIONS FOR QUALITY-IMPROVEMENT APPROACHES TO REDUCING CHILD HEALTH DISPARITIES
Several important factors regarding child health and development affect how health care organizations and policy makers should use quality-improvement approaches to reduce child health disparities. First, preventive health issues are particularly prominent for children compared with adults, and most children do not have chronic health conditions. Second, developmental issues related to physical, cognitive, emotional, and behavioral health are especially critical for children. Multiple nonhealth factors, such as socioeconomics and education, have a critical effect on health outcomes. Many of the most important developmental outcomes are apparent only over the long-term. Early intervention for many of these life-course development issues occur at key formative times and have downstream benefits that may be cost-effective, given a long-term perspective. Third, communication between parents and providers should be strengthened, and parents' psychosocial issues must be addressed in the context of the child's care. Fourth, many of the most vulnerable children have Medicaid coverage, so Medicaid policy and reimbursement have a major influence on the feasibility and sustainability of disparity interventions.
On the basis of the lessons learned from the adult literature, our review of quality-improvement interventions for asthma and immunizations, and special considerations for child health and development, we make the following recommendations to providers, health care organizations, researchers, and funders for using quality-improvement approaches to reduce child health disparities.
Examine your own performance data stratified according to insurance status, race or ethnicity, language, and socioeconomic status. Self-examination of one's own data is a critical initial step.
Measure and improve childhood health-related quality-of-life, development, and condition-specific targets (such as asthma and immunizations).43 Improving care for specific conditions is a useful component of plans to reduce childhood disparities; however, improving condition-specific care encompasses only a small part of the overall scope of child health.
Measure and improve anticipatory guidance for the prevention of conditions such as injuries, violence, substance abuse, and sexually transmitted diseases.13–15,44–46 Similarly, measure and improve efforts to promote positive growth such as readership programs to improve low literacy.47,48
Measure and improve structural aspects of the care experience that affect child health outcomes and can probably reduce disparities. For example, elements of the patient-centered medical home, such as access, care coordination, and communication, affect child health outcomes and are ripe for quality improvement. Some children, such as those with special health care needs or behavioral disorders, frequently receive fragmented care, so integration across providers and care settings is vital.
Incorporate families into interventions.
Use multidisciplinary teams with close tracking and follow-up of patients.
Integrate non–health care partners such as community-based social service agencies into quality- improvement interventions. Perhaps even more so than for adults, it is critical to address home and community factors that affect child well-being to improve outcomes.7 We need to go beyond the traditional paradigm of limiting health care quality improvement to the clinic or hospital setting.
Culturally tailor quality improvement.
Align financial incentives to reduce disparities.
Funders should support more disparity-intervention studies that address these recommendations and analyze clinical outcomes, the intervention-implementation process, and costs. To reduce child health disparities, the managers and policy makers responsible for the widespread dissemination and translation of successful interventions require this detailed information.
The National Institutes of Health and other funders need to support the creation of a new cadre of child health services researchers with the skills needed to find innovative quality-improvement approaches for reducing disparities. The training of these researchers should cover quality improvement, measurement, social sciences relevant to childhood health and development, collaborative transdisciplinary research teamwork, and community-based participatory research techniques.
To reduce child health disparities, we must expand our vision of what constitutes health care quality improvement. Successful efforts require transdisciplinary teams and leaders with the technical and interpersonal skills needed to bridge the medical and community worlds. Funders need to create incentives for investigators to enter the disparities-intervention field. Funders also need to target the high-priority intervention, implementation, and translational research topics identified in this article. Quality improvement is a powerful tool for reducing disparities if we harness it creatively. Although much more research is necessary, the general principles for successful interventions for reducing disparities are known; thus, the time for action is now.
This project was supported by National Institute of Diabetes and Digestive and Kidney Diseases Diabetes Research and Training Center grant P60 DK20595 and the Robert Wood Johnson Foundation Finding Answers: Disparities Research for Change program. Dr Chin is supported by Midcareer Investigator Award in Patient-Oriented Research K24 DK071933 from the National Institute of Diabetes and Digestive and Kidney Diseases.
- Accepted July 20, 2009.
- Address correspondence to Marshall H. Chin, MD, MPH, University of Chicago, Section of General Internal Medicine, 5841 S Maryland Ave, MC 2007, Chicago, IL 60637. E-mail:
The views presented in this article are those of the authors, not the organizations with which they are affiliated.
Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.
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- Copyright © 2009 by the American Academy of Pediatrics