1.1. Background

For at least three decades, a growing body of evidence has documented the problem of health and healthcare disparities, defined as preventable differences in disease burden, injury, violence, or opportunities to achieve optimal health among socially disadvantaged populations.¹ Health disparities have reached crisis proportions among racial and ethnic groups across the United States.² The COVID-19 pandemic, which further exposed and worsened healthcare inequities, led to a renewed call for action and accountability.³ Data show that racially and ethnically minoritized people have higher rates of morbidity and mortality across many health conditions, including chronic conditions such as mental health disorders, cardiovascular disease (including hypertension), cancer, asthma, HIV/AIDS, renal disease, chronic obstructive pulmonary disease (COPD), and diabetes.⁴ Broadly, in most examinations of long-term health and healthcare disparities, African Americans/Blacks fare worse than all other groups in health outcomes.⁵

Figure 1 provides a conceptual framework drawn from the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework and the work of Purnell and colleagues, both of which consider the many factors that influence disparities in health and healthcare.^{6, 7} Racial and ethnic disparities occur in the context of broader inequality and are directly related to the historical and current unequal distribution of social, political, economic, environmental, educational, and healthcare factors and systems.⁸ These include economic policies and systems, development agendas, social norms, social policies, structural racism and discrimination, climate change, healthcare financing, and political structures that shape the conditions in which people are born, work, live, learn, play, worship, and grow older—factors and systems also known as social determinants of health.

Figure 1

Understanding the drivers of and interventions for health and healthcare disparities.

Within this conceptual framework, healthcare-related factors are a critical concern. Addressing racial and ethnic health and healthcare disparities in the United States would not only eliminate much unnecessary human suffering, but also decrease healthcare expenditures. Health disparities are estimated to account for $93 billion in excess medical care costs and $42 billion in untapped productivity.⁹ Specifically, to reduce healthcare expenditures, healthcare systems can focus on patient, clinician, and healthcare system factors (Figure 1).^{10, 11} Patient factors that might affect disparities include individual beliefs and preferences, health behaviors, and mitigating the impact of social determinants of health (e.g., housing, education, employment, socio-economic status).¹⁰ Clinician factors can include knowledge, attitudes, racial bias, implicit or not, practice, and financial incentives. Healthcare system factors can include healthcare organizational culture, quality improvement, and elements of the healthcare system (e.g., organization, financing, care delivery).¹⁰

The federal government has contributed important work to draw attention to and support efforts to reduce disparities. The Department of Health and Human Services’ Healthy People 2000 established national objectives for improving health and well-being that recognized health equity as a goal.¹² Since then, efforts to eliminate disparities have increased. The President’s Office recently signed an executive order on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, followed by the release of actionable recommendations in the Health Equity Task Force report.^{13, 14} However, much remains to be done, given that many factors contribute to disparities.

Healthcare strategies/interventions might offer ways to address racial and ethnic health and healthcare disparities. Our conceptual framework suggests that healthcare strategies/interventions may be complex in design and implementation. They may take place at a single level (i.e., target only one part of the healthcare system such as solely patients, solely clinicians, or solely the healthcare organization) or involve multiple levels of the healthcare system (i.e., target more than one part of the healthcare system such as both clinicians and the healthcare organization).

1.2. Purpose and Scope

Our report supplements an Agency for Healthcare Research and Quality (AHRQ) 2012 report that examined the effectiveness of quality improvement interventions in reducing disparities in health and healthcare on a limited set of clinical conditions.¹⁵ Here we expand the scope of that report by including an unrestricted set of chronic conditions in adults. Also, the 2012 report only included studies if they directly compared a population that was experiencing disparities with a population that was not in order to determine whether the intervention closed the distance between the two groups’ health outcomes. We did not constrain the intervention comparisons to populations only, which allowed a broader range of healthcare strategies/interventions to be examined.

This Technical Brief presents an evidence map based on a systematic search of the recent literature on healthcare strategies/interventions for reducing racial and ethnic disparities and improving health outcomes in the prevention/treatment of chronic conditions in adults. The aim is to identify existing interventions that could be considered for implementation by healthcare system leaders and policymakers, and to inform researchers and funding agencies on gaps in knowledge and research needs.

1.3. Guiding Questions

We developed the questions below in collaboration with AHRQ to guide our mapping of the available evidence.