An Unexpected Answer to Disparities in Hospital Care

    • December 16, 2013

It is widely known that Blacks, Hispanics, and other minorities have poorer health outcomes than Whites, yet in spite of that sobering reality, there has been little or no improvement in these statistics.

Ashish Jha, MD, MPH, used an award from the Robert Wood Johnson Foundation Physician Faculty Scholars program to conduct research, the findings of which suggested a new and straightforward way of improving racial and ethnic disparities in hospital care. In the process, he has spawned a whole new field of inquiry.

One reason for the lack of improvement in health disparities might be that most efforts tend to be diffuse—for example, looking at what all 5,000 hospitals in the country can do to tackle disparities. But Jha’s preliminary research revealed a telling finding—only a small percentage of hospitals care for most Black and Hispanic patients.

Learning to focus on a smaller number of hospitals. Jha’s data showed that 5 percent of hospitals—250 hospitals—care for 50 percent of all Black and 20 percent of all hospitals care for 90 percent of all African Americans. He found similar data for Hispanics.

“If you are interested in improving the care of Blacks in hospitals, you shouldn’t focus on all 5,000 hospitals,” said Jha, professor of health policy and management at the Harvard School of Public Health. “You should focus on the 5 to 25 percent of hospitals where all the action is. That is an opportunity to re-think our approach to disparities.”

To explore his hypothesis further, Jha needed to analyze large datasets—an expensive undertaking that requires the skills of programmers and money for surveys. Awards available to young faculty typically do not cover such expenses.

Jha, however, found such support in the RWJF Physician Faculty Scholars program. The three-year career development award, which Jha received in 2006, gave him the salary support and time he needed to focus his research on looking for ways to improve racial and health care disparities.

RWJF Physician Faculty Scholars, which ran from 2006 through November 2012, sought to strengthen junior medical faculty’s leadership skills and academic productivity. Scholars received funds for a three-year research project, along with mentoring, networking, and other supports. Read the Program Results Report for more information on the program.

An antidote to an “isolating experience.” “When you are a junior faculty member it’s sort of an isolating experience,” Jha said. “Most of the time you are on your own. A big gap that the annual RWJF Physician Faculty Scholars conference filled was creating a community of relatively junior researchers who could come together. It lets you get out of your institution and meet a lot of terrific faculty.

“It was also valuable in getting other perspectives,” he said. “As a junior faculty you are narrowly focused and usually working with just two or three people. Being part of a national community of researchers and having access to senior people across multiple institutions gives you a much broader, more nuanced perspective.”

Examining the capabilities of hospitals caring for Black and Hispanic Americans. “There are two ways to reduce disparities,” Jha said. “One is targeting patients. The other is targeting the institutions that care for those patients. Maybe we need to think about institutions and the role they play in providing care rather than just targeting patients.”

In examining the hospitals that disproportionately care for Black and Hispanic Americans, Jha looked at what kind of infrastructure the institutions had to provide quality health care and promote safety. ”We wanted to know ‘What are these institutions, what are their challenges, and how can we help them get better?’” Jha said.

Jha and his colleagues found that many were lacking some of the basics. For example, hospitals that serve a disproportionately large share of poor patients are lagging behind other hospitals in adopting electronic health records. Jha’s study of these hospitals, published in Health Affairs in 2009, suggested that the digital divide could exacerbate health care disparities, Jha said.

How health information technology can address disparities. “Health information technology is central to improving the quality and efficiency of health care in America,” Jha said. “Health information technology is woefully inadequate throughout the health care system, but institutions that treat the most vulnerable patients have much less of it and this leads to worse care.”

The study found that adoption of electronic health records had the potential to eliminate gaps in disparities in care for patients. For example, Jha said that differences in quality between hospitals that disproportionately care for poor patients and those that do not were essentially erased among electronic health record adopters.

“How much of disparities are because institutions that disproportionately take care of minority patients are not as equipped to care for them?” Jha asked. “What I often say is that they are not able to provide comparable quality care.”

Seeding a new field. Unlike his other research projects that have yielded a single product, Jha’s current focus on targeting institutions that serve disproportionately large numbers of minorities has launched a whole new field of study. He estimates that 20 to 30 papers have looked at minority-serving institutions using the framework that Jha developed. Among them are papers on disparities in trauma centers and disparities in nursing homes.

“We were able to take a concept and get it launched. A lot of people have taken this and run with it in a way that I couldn’t have,” Jha said. “One of the nice things is that people stop paying attention to who initially came up with the idea. It becomes part of the larger landscape of discussion. I’m completely unbothered by that. It’s about getting people to start thinking differently, and that’s what you hope to do with research.”

RWJF perspective. Because many scholars are still early in their careers, it may be too soon to judge the real impact of RWJF Physician Faculty Scholars. However, several scholars currently hold leadership positions in academic medical centers and in local, state, and federal government, and conduct innovative research projects with the potential to affect health and health care.

“The Physician Faculty Scholars program developed a cadre of physicians—65 in total—who will or who have become productive, creative, and influential physician-researchers and leaders,” said RWJF Senior Program Officer David M. Krol, MD, MPH. “It also filled a niche for some physicians who wanted to pursue research that would likely not have been funded by other sources.”

Jha said that RWJF Physician Faculty Scholars was a critical catalyst for moving his research forward. “I could have spent a lot of time in my first years getting the funding,” he said. “[The program] gave me the protected time that I needed as well as the mentoring to move my work along faster than I could have otherwise.”

Ashish Jha, MD, MPH

Ashish Jha, MD, MPH
RWJF Physician Faculty Scholar

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Ashish Jha's unexpected finding re: disparities in hospital care spawns promising new area of inquiry