Fighting unequal treatment: the Robert Wood Johnson Foundation and a quality-improvement approach to disparities.

Ensuring that all Americans have access to quality health care is one of the major goals of The Robert Wood Johnson Foundation (RWJF), as is improving the quality of health care for people with chronic conditions. Working toward this goal means that we must eliminate the embarrassing and unacceptable gaps in health care experienced by racial and ethnic minorities. Research indicates that Americans do not receive half of the care that experts recommend,1 but the evidence also indicates that these quality gaps are even worse for racial and ethnic minorities.2 Disparities in treatment exist across a wide range of chronic conditions, and the evidence of differential treatment is particularly strong with regard to treatment for cardiovascular conditions such as myocardial infarction and congestive heart failure.3 Even though disparities in care have not been conclusively linked to disparities in health outcomes, many experts believe that persistent patterns of lower-quality care for minority Americans do contribute to worse health outcomes, which could explain in part the disproportionate impact of heart disease on minority Americans. Mortality rates from cardiovascular disease are higher among blacks than whites,4 and one study found that heart disease accounted for nearly one third of the overall mortality difference between black and white patients.5 For all of these reasons, efforts to reduce disparities in cardiovascular care are likely to be particularly important in closing gaps in care and will be a high priority for RWJF in the next half decade. This editorial describes the foundation’s approach to reducing racial and ethnic disparities in health care and the underlying rationale for the strategy. For RWJF, developing a new targeted strategy for funding work to reduce racial and ethnic disparities in care required an immediate emphasis on discovering or helping to develop replicable solutions. We believe in supporting projects that have measurable impact on Americans’ health and health care. Many worthy projects or initiatives have either appeared on the scene or picked up momentum since the Institute of Medicine published Unequal Treatment in 2002, its landmark report reviewing the extensive evidence on racial and ethnic disparities in health care. Many of these efforts are, by necessity, focused on long-term goals (such as the diversification of the healthcare professions) or hard-to-measure goals (such as training providers to be more culturally competent) that may take years to bear fruit by way of concrete, measurable improvements in the quality of health care. These approaches are important and necessary; however, RWJF chose to take a complementary path with shorter-term goals. Although we had supported many projects aimed at improving the health and health care of racially and ethnically diverse populations, our disparities strategy was going to be different: a tightly targeted effort to help healthcare systems focus on healthcare disparities experienced by racial and ethnic populations as a quality-of-care problem, with qualityimprovement methodologies as the starting point for solutions. Therefore, the Foundation’s approach to disparities builds as much on our work in quality improvement as it does on our programs such as Hablamos Juntos (“We Speak Together”), which supports demonstration projects to improve communication between providers and patients who have limited Englishspeaking skills. We will help healthcare systems (more specifically, health plans, providers, purchasers, and consumers) ensure that addressing racial and ethnic disparities in treatment is a high priority in their ongoing efforts to improve the quality of care for patients. In fact, we believe that healthcare systems cannot effectively move their quality-improvement goals forward without specifically taking on the embedded problem of racial and ethnic disparities in treatment. For the next 5 years, the Foundation is committed to a series of targeted investments to different entities that play major roles in America’s healthcare system. In addition, we are supporting research to improve understanding of the contributing factors behind disparities between white and nonwhite patients and to use this knowledge to help health plans and providers identify disparities in care where they occur and design interventions to address them. We will focus on particular conditions, such as diabetes and cardiac disease, which have a particularly large impact on minority populations and for which there is a strong evidence base for a recommended standard of care for all patients.6 Although we are aware that factors beyond the influence of the healthcare system obviously contribute to gaps in treatment (such as health insurance coverage, the quality of one’s provider in a particular geographic area, and personal health behaviors), our efforts will stimulate healthcare systems to develop interventions that ensure minority patients are receivThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From The Robert Wood Johnson Foundation, Princeton, NJ. The Robert Wood Johnson Foundation, based in Princeton, NJ, is the nation’s largest philanthropy devoted exclusively to health and health care. It concentrates its grant making in 4 goal areas: To assure that all Americans have access to quality health care at reasonable cost; to improve the quality of care and support for people with chronic conditions; to promote healthy communities and lifestyles; and to reduce the personal, social, and economic harm caused by substance abuse— tobacco, alcohol, and illicit drugs. Correspondence to Minna Jung, JD, Communications Officer, The Robert Wood Johnson Foundation, Route 1 and College Rd E, Princeton, NJ 08543-2316. E-mail [email protected] (Circulation. 2005;111:1208-1209.) © 2005 American Heart Association, Inc.