Journal of General Internal Medicine

, Volume 23, Issue 5, pp 672–677

Reducing Disparities Downstream: Prospects and Challenges

Health Policy

Summary

Addressing upstream or fundamental causes (such as poverty, limited education, and compromised healthcare access) is essential to reduce healthcare disparities. But such approaches are not sufficient, and downstream interventions, addressing the consequences of those fundamental causes within the context of any existing health system, are also necessary. We present a definition of healthcare disparities and two key principles (that healthcare is a social good and disparities in outcomes are a quality problem) that together provide a framework for addressing disparities downstream. Adapting the chronic care model, we examine a hierarchy of three domains for interventions (health system, provider–patient interactions, and clinical decision making) to reduce disparities downstream and discuss challenges to implementing the necessary changes.

KEY WORDS

healthcare disparity poverty downstream upstream education 

References

  1. 1.
    Lleras-Muney A. The relationship between education and adult mortality in the United States. Rev Econ Stud. 2005;72(1):189–221.Google Scholar
  2. 2.
    Starfield B, Birn AE. Income redistribution is not enough: income inequality, social welfare programs, and achieving equity in health. J Epidemiol Community Health. 2007;61(12):1038–41.PubMedGoogle Scholar
  3. 3.
    Andrulis DP. Access to care is the centerpiece in the elimination of socioeconomic disparities in health. Ann Intern Med. 1998;129(5):412–16.PubMedGoogle Scholar
  4. 4.
    Leyland AH. Increasing inequalities in premature mortality in Great Britain. J Epidemiol Community Health. 2004;58(4):296–302.PubMedGoogle Scholar
  5. 5.
    Burstrom K, Johannesson M, Diderichsen F. Increasing socio-economic inequalities in life expectancy and QALYs in Sweden 1980–1997. Health Econ. 2005;14(8):831–50.PubMedGoogle Scholar
  6. 6.
    Fairley L, Leyland AH. Social class inequalities in perinatal outcomes: Scotland 1980–2000. J Epidemiol Community Health. 2006;60(1):31–6.PubMedGoogle Scholar
  7. 7.
    Victora CG, Vaughan JP, Barros FC, Silva AC,Tomasi E. Explaining trends in inequities: evidence from Brazilian child health studies. Lancet. 2000;356(9235):1093–98.PubMedGoogle Scholar
  8. 8.
    Goldman DP, Lakdawalla D. A theory of health disparities and medical technology. Contrib Econ Anal Policy. 2005;4(1):1395.Google Scholar
  9. 9.
    Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C.: National Academy Press; 2002.Google Scholar
  10. 10.
    Agency for Healthcare Research and Quality. National Healthcare Disparities Report 2006. Rockville, MD: Agency for Healthcare Research and Quality; 200728 January, http://www.ahrq.gov/qual/nhdr06/nhdr06.htm.Google Scholar
  11. 11.
    Fiscella K. Eliminating disparities in health care through quality improvement. In: Williams RA, ed. Eliminating Healthcare Disparities in America: Beyond the IOM Report. Totowa, NJ: Humana Press; 2007:1–2.Google Scholar
  12. 12.
    Escarce JJ, Kapur K. Racial and ethnic differences in public and private medical care expenditures among aged Medicare beneficiaries. Milbank Q. 2003;81(2):249–75, 172.PubMedGoogle Scholar
  13. 13.
    Rathore SS, Foody JM, Wang Y, et al. Race, quality of care, and outcomes of elderly patients hospitalized with heart failure. JAMA. 2003;289(19):2517–24.PubMedGoogle Scholar
  14. 14.
    Rathore SS, Masoudi FA, Havranek EP, Krumholz HM. Regional variations in racial differences in the treatment of elderly patients hospitalized with acute myocardial infarction. Am J Med. 2004;117(11):811–22.PubMedGoogle Scholar
  15. 15.
    Nichol KL. Long-term success with the national health objective for influenza vaccination: an institution-wide model. J Gen Intern Med. 1992;7(6):595–600.PubMedGoogle Scholar
  16. 16.
    Horner RD, Oddone EZ, Stechuchak KM, et al. Racial variations in postoperative outcomes of carotid endarterectomy: evidence from the Veterans Affairs National Surgical Quality Improvement Program. Med Care. 2002;40(1 Suppl):I35–43.PubMedGoogle Scholar
  17. 17.
    Kerr EA, Gerzoff RB, Krein SL, et al. Diabetes care quality in the Veterans Affairs Health Care System and commercial managed care: the TRIAD study. Ann Intern Med. 2004;141(4):272–81.PubMedGoogle Scholar
  18. 18.
    Deswal A, Petersen NJ, Souchek J, Ashton CM, Wray NP. Impact of race on health care utilization and outcomes in veterans with congestive heart failure. J Am Coll Cardiol. 2004;43(5):778–84.PubMedGoogle Scholar
  19. 19.
    Sehgal AR. Impact of quality improvement efforts on race and sex disparities in hemodialysis. JAMA. 2003;289(8):996–1000.PubMedGoogle Scholar
  20. 20.
    Sequist TD, Adams A, Zhang F, Ross-Degnan D, Ayanian JZ. Effect of quality improvement on racial disparities in diabetes care. Arch Intern Med. 2006;166(6):675–81.PubMedGoogle Scholar
  21. 21.
    Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med. 2005;353(7):692–700.PubMedGoogle Scholar
  22. 22.
    Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57(4):254–8.PubMedGoogle Scholar
  23. 23.
    Rathore SS, Krumholz HM. Differences, disparities, and biases: clarifying racial variations in health care use. Ann Intern Med. 2004;1418635–8.PubMedGoogle Scholar
  24. 24.
    Kilbourne AM, Switzer G, Hyman K, Crowley-Matoka M, Fine MJ. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health. 2006;96(12):2113–21.PubMedGoogle Scholar
  25. 25.
    Starfield B. Pathways of influence on equity in health. Soc Sci Med. 2007;64(7):1355–62.PubMedGoogle Scholar
  26. 26.
    Isaacs SL, Schroeder SA. Class—the ignored determinant of the nation’s health. N Engl J Med. 2004;351(11):1137–42.PubMedGoogle Scholar
  27. 27.
    Kawachi I, Daniels N, Robinson DE. Health disparities by race and class: why both matter. Health Aff (Millwood). 2005;24(2):343–52.Google Scholar
  28. 28.
    Muennig P, Franks P, Jia H, Lubetkin E, Gold MR. The income-associated burden of disease in the United States. Soc Sci Med. 2005;61(9):2018–26.PubMedGoogle Scholar
  29. 29.
    Franks P, Muennig P, Lubetkin E, Jia H. The burden of disease associated with being African-American in the United States and the contribution of socio-economic status. Soc Sci Med. 2006;62(11):2469–78.PubMedGoogle Scholar
  30. 30.
    Pellegrino ED. The commodification of medical and health care: the moral consequences of a paradigm shift from a professional to a market ethic. J Med Philos. 1999;24(3):243–66.PubMedGoogle Scholar
  31. 31.
    Hart JT. The inverse care law. Lancet. 1971;1(7696):405–12.PubMedGoogle Scholar
  32. 32.
    Ko DT, Mamdani M, Alter DA. Lipid-lowering therapy with statins in high-risk elderly patients: the treatment-risk paradox. JAMA. 2004;291(15):1864–70.PubMedGoogle Scholar
  33. 33.
    Fiscella K, Franks P, Gold M, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000;283(19):2579–84.PubMedGoogle Scholar
  34. 34.
    Asch SM, Kerr EA, Keesey J, et al. Who is at greatest risk for receiving poor-quality health care? N Engl J Med. 2006;354(11):1147–56.PubMedGoogle Scholar
  35. 35.
    Margolis ML, Christie JD, Silvestri GA, Kaiser L, Santiago S, Hansen-Flaschen J. Racial differences pertaining to a belief about lung cancer surgery: results of a multicenter survey. Ann Intern Med. 2003;139(7):558–63.PubMedGoogle Scholar
  36. 36.
    Mukamel DB, Murthy AS, Weimer DL. Racial differences in access to high-quality cardiac surgeons. Am J Public Health. 2000;90(11):1774–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Doescher MP, Saver BG, Franks P, Fiscella K. Racial and ethnic disparities in perceptions of physician style and trust. Arch Fam Med. 2000;9(10):1156–63.PubMedGoogle Scholar
  38. 38.
    Baicker K, Chandra A, Skinner JS, Wennberg JE. Who you are and where you live: how race and geography affect the treatment of Medicare beneficiaries. Health Aff (Millwood). 2004;(Suppl Web Exclusives):VAR33–44.Google Scholar
  39. 39.
    Restuccia JD, Shwartz M, Kreger BE, et al. Does more “appropriateness” explain higher rates of cardiac procedures among patients hospitalized with coronary heart disease? Med Care. 2002;40(6):500–9.PubMedGoogle Scholar
  40. 40.
    Brook RH, Ware JE Jr, Rogers WH, et al. Does free care improve adults’ health? Results from a randomized controlled trial. N Engl J Med. 1983;309:1426–34.PubMedCrossRefGoogle Scholar
  41. 41.
    Institute of Medicine. Committee on Monitoring Access to Personal Health Care Services. In Millman ML, ed. Access to health care in America/Committee on Monitoring Access to Personal Health Care Services, Institute of Medicine. Washington, D.C.: National Academy Press; 1993.Google Scholar
  42. 42.
    Benzeval M, Judge K, Whitehead M. Tackling Inequalities in Health: An Agenda for Action. London: King’s Fund; 1995.Google Scholar
  43. 43.
    Bierman AS, Magari ES, Jette AM, Splaine M, Wasson JH. Assessing access as a first step toward improving the quality of care for very old adults. J Ambul Care Manage. 1998;21(3):17–26.PubMedGoogle Scholar
  44. 44.
    Aday LA. Reinventing Public Health: Policies and Practices for a Healthy Nation, 1st ed. San Francisco, CA: Jossey-Bass; 2005.Google Scholar
  45. 45.
    Cooper LA, Hill MN, Powe NR. Designing and evaluating interventions to eliminate racial and ethnic disparities in health care. J Gen Intern Med. 2002;17(6):477–86.PubMedGoogle Scholar
  46. 46.
    Chin MH, Walters AE, Cook SC, Huang ES. Interventions to reduce racial and ethnic disparities in health care. Med Care Res Rev. 2007;64(5 Suppl)7S–28S.PubMedGoogle Scholar
  47. 47.
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001;20(6):64–78.Google Scholar
  48. 48.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288(14):1775–9.PubMedGoogle Scholar
  49. 49.
    Health Disparities Collaborative. Models for Changing Practice. http://www.healthdisparities.net/hdc/html/about.hdcModels.aspx. October 9 and November 28, 2007.
  50. 50.
    Shapiro S, Venet W, Strax P, Venet L, Roeser R. Prospects for eliminating racial differences in breast cancer survival rates. Am J Pub Health. 1982;72:1142–5.Google Scholar
  51. 51.
    Hypertension Detection and Follow-up Program Cooperative Group. Five-year findings of the hypertension detection and follow-up program. II. Mortality by race-sex and age. JAMA. 1979;242(23):2572–7.Google Scholar
  52. 52.
    Goldman DP, Smith JP. Can patient self-management help explain the SES health gradient. Proc Natl Acad Sci U S A. 2002;99(16):10929–34.PubMedGoogle Scholar
  53. 53.
    Smith JL, Rost KM, Nutting PA, Elliott CE, Dickinson LM. Impact of ongoing primary care intervention on long term outcomes in uninsured and insured patients with depression. Med Care. 2002;40(12)1210–22.PubMedGoogle Scholar
  54. 54.
    Wells K, Sherbourne C, Schoenbaum M, et al. Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial. Arch Gen Psychiatry. 2004;61(4):378–86.PubMedGoogle Scholar
  55. 55.
    Szilagyi PG, Schaffer S, Shone L, et al. Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. Pediatrics. 2002;110(5):e58.PubMedGoogle Scholar
  56. 56.
    Freeman HP, Muth BJ, Kerner JF. Expanding access to cancer screening and clinical follow-up among the medically underserved. Cancer Pract. 1995;3(1):19–30.PubMedGoogle Scholar
  57. 57.
    Paskett E, Tatum C, Rushing J, et al. Randomized trial of an intervention to improve mammography utilization among a triracial rural population of women. J Natl Cancer Inst. 2006;98(17):1226–37.PubMedGoogle Scholar
  58. 58.
    Nerenz DR. Health care organizations’ use of race/ethnicity data to address quality disparities. Health Aff (Millwood). 2005;24(2):409–16.Google Scholar
  59. 59.
    Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. Primary care physicians who treat blacks and whites. N Engl J Med. 2004;351(6):575–84.PubMedGoogle Scholar
  60. 60.
    Pham HH, Schrag D, Hargraves JL, Bach PB. Delivery of preventive services to older adults by primary care physicians. JAMA. 2005;294(4):473–81.PubMedGoogle Scholar
  61. 61.
    Morales LS, Staiger D, Horbar JD, et al. Mortality among very low-birthweight infants in hospitals serving minority populations. Am J Public Health. 2005;95(12):2206–12.PubMedGoogle Scholar
  62. 62.
    Trivedi AN, Sequist TD, Ayanian JZ. Impact of hospital volume on racial disparities in cardiovascular procedure mortality. J Am Coll Cardiol. 2006;47(2):417–24.PubMedGoogle Scholar
  63. 63.
    Fiscella K, Geiger HJ. Health information technology and quality improvement for community health centers. Health Aff (Millwood). 2006;25(2):405–12.Google Scholar
  64. 64.
    Casalino LP, Elster A. Will pay-for-performance and quality reporting affect health care disparities. Health Aff (Millwood). 2007;26(3):w405–14.Google Scholar
  65. 65.
    Franks P, Clancy CM. Referrals of adult patients from primary care: demographic disparities and their relationship to HMO insurance. J Fam Pract. 1997;45:47–53.PubMedGoogle Scholar
  66. 66.
    DeLaet DE, Shea S, Carrasquillo O. Receipt of preventive services among privately insured minorities in managed care versus fee-for-service insurance plans. J Gen Intern Med. 2002;17(6):451–7.PubMedGoogle Scholar
  67. 67.
    Bindman AB, Chattopadhyay A, Osmond DH, Huen W, Bacchetti P. The impact of Medicaid managed care on hospitalizations for ambulatory care sensitive conditions. Health Serv Res. 2005;40(1):19–38.PubMedGoogle Scholar
  68. 68.
    Balsa AI, Cao Z, McGuire TG. Does managed health care reduce health care disparities between minorities and Whites? J Health Econ. 2007;26(1):101–21.PubMedGoogle Scholar
  69. 69.
    Fiscella K, Franks P, Doescher MP, Saver BG. Do HMOs affect educational disparities in health care? Ann Fam Med. 2003;1(2):90–6.PubMedGoogle Scholar
  70. 70.
    Schneider EC, Zaslavsky AM, Epstein AM. Racial disparities in the quality of care for enrollees in Medicare managed care. JAMA. 2002;287(10):1288–94.PubMedGoogle Scholar
  71. 71.
    Schneider EC, Cleary PD, Zaslavsky AM, Epstein AM. Racial disparity in influenza vaccination: does managed care narrow the gap between African Americans and whites? JAMA. 2001;286(12):1455–60.PubMedGoogle Scholar
  72. 72.
    O’Connell L, Brown SL. Do nonprofit HMOs eliminate racial disparities in cardiac care? J Health Care Finance. 2003;30(2):84–94.PubMedGoogle Scholar
  73. 73.
    Ponce NA, Huh S, Bastani R. Do HMO market level factors lead to racial/ethnic disparities in colorectal cancer screening? A comparison between high-risk Asian and Pacific Islander Americans and high-risk whites. Med Care. 2005;43(11):1101–8.PubMedGoogle Scholar
  74. 74.
    Nerenz D, Bonham VL, Green-Weir , Joseph C, Gunter M. Eliminating racial/ethnic disparities in health care: can health plans generate reports? Health Aff (Millwood). 2002;21(3):259–63.Google Scholar
  75. 75.
    AHRQ. Major Health Plans and Organizations Join AHRQ to Reduce Racial and Ethnic Disparities in Health Care. Press Release. www.ahrq.gov/news/press/pr2004/dispcolpr.htm (21 December). December 24, 2004.
  76. 76.
    Johnson RL, Roter D, Powe N, Cooper LA. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health. 2004;94(12):2084–90.PubMedGoogle Scholar
  77. 77.
    van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med. 2000;50(6):813–28.PubMedGoogle Scholar
  78. 78.
    Balsa AI, McGuire TG, Meredith LS. Testing for statistical discrimination in health care. Health Serv Res. 2005;40(1):227–52.PubMedGoogle Scholar
  79. 79.
    Kaplan SH, Greenfield S. The patient’s role in reducing disparities. Ann Intern Med. 2004;141(3):222–3.PubMedGoogle Scholar
  80. 80.
    Krupat E, Irish JT, Kasten LE, et al. Patient assertiveness and physician decision-making among older breast cancer patients. Soc Sci Med. 1999;49(4):449–57.PubMedGoogle Scholar
  81. 81.
    Kalauokalani D, Franks P, Wright Oliver J, Meyers FJ, Kravitz RL. Can patient coaching reduce racial/ethnic disparities in cancer pain control? Secondary analysis of a randomized controlled trial. Pain Medicine. 2007;8(1):17–24.PubMedGoogle Scholar
  82. 82.
    Kukafka R, Lussier YA, Eng P, Patel VL, Cimino JJ. Web-based tailoring and its effect on self-efficacy: results from the MI-HEART randomized controlled trial. Proc AMIA Symp. 2002;410–4.Google Scholar
  83. 83.
    Kreuter MW, Black WJ, Friend L, et al. Use of computer kiosks for breast cancer education in five community settings. Health Educ Behav. 2006;33(5):625–42.PubMedGoogle Scholar
  84. 84.
    Jerant A, Kravitz RL, Rooney M, Amerson S, Kreuter M, Franks P. Effects of a tailored interactive multimedia computer program on determinants of colorectal cancer screening: A randomized controlled pilot study in physician offices. Patient Educ Couns. 2006;66(1):67–74.PubMedGoogle Scholar
  85. 85.
    Balsa AI, McGuire TG. Prejudice, clinical uncertainty and stereotyping as sources of health disparities. J Health Econ. 2003;22(1):89–116.PubMedGoogle Scholar
  86. 86.
    Green A, Carney D, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231–8.PubMedGoogle Scholar
  87. 87.
    Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2006;(2):CD000259.Google Scholar
  88. 88.
    Thomson O’Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2000;(2):CD000409.Google Scholar
  89. 89.
    Madan AK, Caruso BA, Lopes JE, Gracely EJ. Comparison of simulated patient and didactic methods of teaching HIV risk assessment to medical residents. Am J Prev Med. 1998;15(2):114–9.PubMedGoogle Scholar
  90. 90.
    Epstein RM, Levenkron JC, Frarey L, Thompson J, Anderson K, Franks P. Improving physicians’ HIV risk-assessment skills using announced and unannounced standardized patients. J Gen Intern Med. 2001;16(3):176–80.PubMedGoogle Scholar
  91. 91.
    Blake K, Mann KV, Kaufman DM, Kappelman M. Learning adolescent psychosocial interviewing using simulated patients. Acad Med. 2000;75(10 Suppl):S56–8.PubMedCrossRefGoogle Scholar
  92. 92.
    Griffin SJ, Kinmonth AL, Veltman MW, Gillard S, Grant J, Stewart M. Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Ann Fam Med. 2004;2(6):595–608.PubMedGoogle Scholar
  93. 93.
    Beach MC, Price EG, Gary TL, et al. Cultural competence: a systematic review of health care provider educational interventions. Med Care. 2005;43(4):356–73.PubMedGoogle Scholar
  94. 94.
    Beach MC, Rosner M, Cooper LA, Duggan PS, Shatzer J. Can patient-centered attitudes reduce racial and ethnic disparities in care? Acad Med. 2007;82(2):193–8.PubMedGoogle Scholar
  95. 95.
    Burgess D, van RM, Dovidio J, Saha S. Reducing racial bias among health care providers: lessons from social-cognitive psychology. J Gen Intern Med. 2007;22(6):882–7.PubMedGoogle Scholar
  96. 96.
    Okelo S, Taylor AL, Wright JT Jr., Gordon N, Mohan G, Lesnefsky E. Race and the decision to refer for coronary revascularization: the effect of physician awareness of patient ethnicity. J Am Coll Cardiol. 2001;38(3):698–704.PubMedGoogle Scholar
  97. 97.
    Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110(2):227–39.PubMedGoogle Scholar
  98. 98.
    Fiscella K, Franks P. Should years of schooling be used to guide treatment of coronary risk factors? Ann Fam Med. 2004;2(5):469–73.PubMedGoogle Scholar
  99. 99.
    Woodward M, Brindle P, Tunstall-Pedoe H. Adding social deprivation and family history to cardiovascular risk assessment: the ASSIGN score from the Scottish Heart Health Extended Cohort (SHHEC). Heart. 2007;93(2):172–6.PubMedGoogle Scholar
  100. 100.
    Geiger HJ, Betancourt J, Williams DR. Who is at greatest risk for receiving poor-quality health care? N Engl J Med. 2006;354(24):2617–9.PubMedGoogle Scholar
  101. 101.
    Ramirez M, Ford ME, Stewart AL, Teresi A. Measurement issues in health disparities research. Health Serv Res. 2005;40(5p2):1640–57.PubMedGoogle Scholar
  102. 102.
    Hassett P. Taking on racial and ethnic disparities in health care: the experience at Aetna. Health Aff (Millwood). 2005;24(2):417–20.Google Scholar
  103. 103.
    Rowe JW, Cortese DA, McGinnis JM. The emerging context for advances in comparative effectiveness assessment. Health Aff (Millwood). 2006;25(6):w593–5.Google Scholar
  104. 104.
    Hasnain-Wynia, Baker DW. Obtaining data on patient race, ethnicity, and primary language in health care organizations: current challenges and proposed solutions. Health Serv Res. 2006;41(4 Pt 1):1501–18.PubMedGoogle Scholar
  105. 105.
    Krieger N, Williams D, Moss NE. Measuring social class in US public health research: concepts, methodologies, and guidelines. Annu Rev of Public Health. 1997;18:341–8.Google Scholar
  106. 106.
    Carstairs V. Deprivation indices: their interpretation and use in relation to health. J Epidemiol Community Health. 1995;49(Suppl 2):S3–8.PubMedGoogle Scholar
  107. 107.
    Krieger N, Chen JT, Waterman PD, Rehkopf DH, Subramanian SV. Painting a truer picture of US socioeconomic and racial/ethnic health inequalities: the Public Health Disparities Geocoding Project. Am J Public Health. 2005;95(2):312–23.PubMedGoogle Scholar
  108. 108.
    Beach MC, Gary TL, Price EG, et al. Improving health care quality for racial/ethnic minorities: a systematic review of the best evidence regarding provider and organization interventions. BMC Public Health. 2006;6:104.PubMedGoogle Scholar
  109. 109.
    Epstein AM. Pay for performance at the tipping point. N Engl J Med. 2007;356(5):515–7.PubMedGoogle Scholar
  110. 110.
    Aaron KF, Stryer D. Moving from rhetoric to evidence-based action in health care. J Gen Intern Med. 2003;18(7):589–91.PubMedGoogle Scholar
  111. 111.
    Braveman PA. We also need bold experiments: a response to Starfield’s “Commentary: Pathways of influence on equity in health”. Soc Sci Med. 2007;64(7):1363–6.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  1. 1.Center for Healthcare Policy and Research, Department of Family and Community MedicineUniversity of California at DavisSacramentoUSA
  2. 2.Department of Family MedicineUniversity of Rochester School of Medicine and DentistryRochesterUSA
  3. 3.Department of Community and Preventive MedicineUniversity of Rochester School of Medicine and DentistryRochesterUSA

Personalised recommendations