Access to Care and Quality of Care ‘Inseparable’ Concepts

CHICAGO—The Institute of Medicine (IOM) defines health care access as "timely use of affordable, continuous, quality health services which are sensitive to individual needs in order to achieve the best possible health outcomes," Jeanne Mandelblatt, MD, MPH, PhD, said at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University’s annual Health Policy Symposium.

Dr. Mandelblatt, associate professor of medicine, Georgetown University Medical School, and director of Cancer Aging and Cancer Outcomes Research, Lombardi Cancer Center, and Otis W. Brawley, MD, PhD, National Cancer Institute, addressed the meaning of access to health care and its implications for cancer mortality and cancer patient care in their symposium presentations.

According to Dr. Mandelblatt, there are many steps to the cancer care pathway, different points at which patients access care, and different measures for outcomes. The first step for a patient is to enter the physician’s office, often perceived as one of the greatest barriers to access.

Once a patient establishes contact with a physician through an office visit, Dr. Mandelblatt emphasized that after the visit, he or she must be able to successfully interpret the physician’s diagnosis and navigate the health care system.

This "navigation" includes being able to follow-up with screening, understand a potential diagnosis of cancer based on routine or symptomatic screening, obtain a workup and evaluation by the physician if the screening test is positive, review and comprehend different options for therapy, and discuss and come to terms with potential end-of-life care.

Once a patient is able to navigate the system, he or she can obtain "desired access," or appropriate and high-quality health care, she said. Whether patients obtain desired or ideal access can be assessed by comparing desired access with "realized access," which includes the number of patient visits and the impact these visits have on the patient’s quality of life.

Dr. Mandelblatt defined access to quality care as the degree to which health services for individuals and populations have the intended or desired effect. She noted that the concepts of access and quality are inextricably linked and impossible to separate completely.

Several methods are currently in place for measuring the level of access and quality of care. The most common indicators include rates of screening, stage at diagnosis, patient satisfaction, and quality of life. A variety of factors make assessing quality of care and access difficult, however, such as changes in health insurance plans or patient relocation.

Identifying barriers to access is the first step in increasing patients’ participation in their own health care. Dr. Mandelblatt suggested that there are many barriers patients face as they attempt to obtain health care, such as a mismatch in patient and physician communication styles that ultimately leads to a communication breakdown.

Providers may be insensitive to the appropriate ways of providing information to the patient. For example, if a patient is not as highly educated as the physician, he or she may not be able to understand the diagnosis and treatment options, and may not receive the same quality of treatment as others.

Good communication is particularly vital in the case of cancer treatment, where patients are expected to make informed decisions regarding their care. Unfortunately, Dr. Mandelblatt pointed out, most medical schools and residency programs spend little time in helping physicians develop good communication skills.

Barriers to access are frequently encountered by patients with low socioeconomic status, the elderly, the under-insured and uninsured, and minorities. Although the elderly are a heterogeneous group, Dr. Mandelblatt pointed out that elderly patients are consistently under-treated for many cancers. She suggested that health maintenance organizations (HMOs) are losing money in caring for the elderly, and some choose to cover only the "healthiest" of the elderly.

In addition, insurance companies may choose not to provide coverage for particular therapies, which may prevent patients from having the therapy at all. In some cases, the uninsured may not even receive surgical intervention when clinically indicated.

Dr. Mandelblatt referred to one particular study, published in JAMA by Lannin et al, showing that black patients, patients with a per capita income of $10,000 or less, and patients without private health insurance were all more likely to be diagnosed with breast cancer at a later disease stage.[1]

In this study of 540 patients, being black was a significant predictor of late-stage diagnosis (OR 3.0, 95% CI, 1.9-4.7). When race and socioeconomic variables were considered in a multi-variate logistic regression model, the odds ratio for late-stage diagnosis among blacks decreased to 1.8 (95% CI, 1.1-3.2), and when attitudes and beliefs were added to the model, the odds ratio decreased further to 1.2 (95% CI, 0.6-2.5).

The organization of health care may also present barriers to accessing quality care. Dr. Mandelblatt stated that coverage of medical services varies greatly depending on the person’s insurance status. Medicare now covers care for patients enrolled in randomized, controlled clinical trials, she said, which improves access to care for some who might not otherwise receive it.

There are conflicting perspectives in the literature about whether and how managed care organizations vs fee-for-service organizations affect access and quality of care for minorities and the poor.

The IOM recommended that hospitals develop an effective infrastructure of data collection and monitoring of care for determining whether goals for achieving greater access are being met. However, most hospitals do not have such sophisticated infrastructures or the resources to develop them.

How do we overcome barriers to accessing quality health care? Dr. Mandelblatt noted that there are few tested interventions that have been shown to overcome these barriers, but behavioral interventions seem to hold some promise in increasing cancer screening rates.

She concluded that more research needs to be dedicated to areas other than screening. Further studies must be undertaken to address access to care in the context of stage of cancer diagnosis, cancer survivorship, and end-of-life concerns. It will become increasingly important to observe the affect of the shift to managed care on access.

The findings from measured outcome variables need to be widely applied in clinical practice, she said, taking into account the importance of patient preferences. She also recommended expanding the data infrastructure, increasing the number of minority providers, and increasing physician training in communication.

Increasing Access for Minorities

In his presentation, Dr. Brawley said that the gap between cancer mortality rates among blacks and whites has widened in recent years due to minorities’ lack of access to health care.

In the era prior to the discovery of chemotherapy agents and other therapies that have substantially reduced cancer mortality and the widespread use of screening tests that uncover cancer at earlier stages, cancer mortality rates for blacks and whites were similar, he said. As whites, but to a far lesser extent blacks, receive earlier screening and better treatments, the mortality gap continues to grow more and more disparate.

Dr. Brawley commented on the significance of the language used to label those who are disproportionately affected by poor health and have difficulties obtaining quality health care. By using terms, such as "special populations," which imply that these populations are in some way separate and would be privileged to receive additional resources, politicians have sometimes made it difficult to direct attention and funds toward researching causes of health disparities.

He suggested that in order to gain better understanding of the current disparities in health care among racial groups, we must determine "what is known, what is not known, and what is believed."

According to Dr. Brawley, clinicians frequently confuse what is known with what is believed. For instance, many believe that there are underlying biological differences among different racial groups. Just as syphilis was once considered to take a different course in blacks and whites, Dr. Brawley suggested that some clinicians today believe that biological differences lead to worse outcomes in breast and prostate cancer for blacks.

While many scientists, politicians, and journalists encourage the idea of race as a biological cause of illness, Dr. Brawley pointed out that race is, in fact, a new sociological and political construct, less than 300 years old, and one that most anthropologists reject.

When we consider that, for example, at least 70% of blacks have a white North American ancestor, categories that separate blacks, Caucasians, Asian Americans, Hispanics, Pacific Islanders/Hawaiians, etc, along supposed biological lines have little meaning.

Dr. Brawley suggested that examining the differences in access to care rather than searching for biological differences would lead to greater insight into the cancer mortality gap.

Many blacks have limited access to basic health care services. In the cases where black women with breast cancer do access the system, they are less likely to receive hormonal therapy, chemotherapy, and surgery.[2]

Among breast cancer patients in the NCI-sponsored Black-White Cancer Survival Study (BWCSS), 21% of blacks did not receive minimal expected treatment, compared with 15% of whites.[2]

Similar differences exist between black and white colon and lung cancer patients. Prior to 1979, rates of colon cancer surgeries for blacks and whites were similar. As surgical treatments improved, however, blacks became far less likely to receive these treatments than whites. In a study by Greenwald et al, whites were 20% more likely to receive lung cancer surgery than blacks and 31% more likely to survive for 5 years after diagnosis.[3]

Dr. Brawley stated that subtle differences in treatment have led to large differences in quality outcomes for breast cancer care. In some major hospitals that serve predominantly black patients, radiation therapy is not offered at all, and women may wait 6 to 8 hours to be seen for a mammogram. For women who are able to wait that long to obtain the test, it may take 3 months to receive notice of an abnormal mammogram, and many patients never return for their results.

In poorer hospitals, mammogram films are sent away for development, to be read by a different radiologist. Dr. Brawley suggested that women might receive a very different education and treatment if the films were read immediately by an on-site radiologist.

Dr. Brawley noted that mortality rates can be greatly reduced by gaining equal access to care. According to a study of women with breast cancer in the military, where blacks and whites had equal access to care, 5-year mortality rates for black women were reduced by approximately 30% through ready access to care and availability of a full complement of treatments.[4]

In a study by Yood and colleagues,[5] the influence of race on breast cancer mortality rates after adjustment for stage and socioeconomic status became negligible, supporting the notion that there is little, if any, difference in the tumor biology of blacks and whites.

In conclusion, Dr. Brawley emphasized that differences in patterns of care have a clear relationship to differences in mortality. An increasing proportion of poor and minority patients do not receive adequate care in the United States, leading to more advanced disease at diagnosis, higher-grade tumors, and higher mortality rates.

He suggested that the fastest way to reduce mortality rates is through delivering quality health care. Beyond focusing our efforts on research into differences in mortality rates, he said, we must dedicate resources to the provision of care to underserved populations so that more people with cancer will have a chance to survive the disease.

References:

1.  Lannin DR, Mathews HF, et al: Influence of socioeconomic and cultural factors on racial differences in late-stage presentation of breast cancer. JAMA 279:1801-1807, 1998.

2.  Breen N, Wesley MN, et al: The relationship of socio-economic status and access to minimum expected therapy among female breast cancer patients in the National Cancer Institute Black-White Cancer Survival Study. Ethnicity and Disease 9(1):111-125, 1999.

3.  Greenwald HP, Polissar NL, et al: Social factors, treatment, and survival in early-stage non-small cell lung cancer. Am J Pub Health 88(11):1681-1684, 1998.

4.  Wojcik BE, Spinks MK, Optenberg SA, et al: Breast carcinoma survival analysis for African American and white women in an equal-access health care system. Cancer 82(7):1310-1318, 1998.

5.  Yood MU, Johnson CC, et al: Race and differences in breast cancer survival in a managed care population. J Natl Cancer Inst 91:1487-1491, 1999.