I first began writing formal critiques as assignments for an introductory Global Public Health course at Worcester Polytechnic Institute taught by Dr. Nicola Bulled. One of the student goals of the course was achieving proficiency in critiquing public health articles and policy briefs. Before writing one of our own policy briefs, Dr. Bulled assigned us to critique the brief linked below.
Health Affairs. Achieving Equity in Health. October 2011. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_53.pdf
Health disparities afflict racial and ethnic minorities in America, both in health and care received. Minorities have higher rates of age-adjusted death, infant mortality, breast cancer, heart failure, diabetes, stroke, and related preventable diseases and conditions, which expose the irrefutable fact that health disparities exist as a result of race and ethnicity (pg. 1-3). Why? Factors that determine health status in life include: behavior, genetics, access to health care, and social and economic determinants. Social and economic outcomes are driven by determinants involving education, income level, and living conditions (pg. 2). Examination of the sources of disparity highlight the federal poverty line, the last level of education obtained, health coverage, levels of stress (often related to employment and income), and rural versus urban home settings as key determinants in someone’s health (pg. 3). Despite having worse health, racial and ethnic minorities receive inadequate care, resulting in a vicious cycle. Hospitals that are high-cost with low-quality care are found to serve the greatest population of elderly black patients (pg. 4). Health coverage is the most significant contributing factor for health care received, as the rates of uninsured people being recommended specific care are disproportionality lower than those with proper coverage (pg. 4). On the side of the health system, doctors cite communication difficulties and non-adherence to treatment as two main barriers (pg. 5). Several policy recommendations are made, which call for more attention to lessening the social determinants of health, and increasing health insurance for more Americans. More research is requested in an effort to better understand health disparities, and more assessments to measure the situation before and after policy implementation (pg. 6).
Critique with Suggestions for Improvement
In the policy brief, the authors referenced The Agency for Healthcare Research in regards to their annual disparities report. In reference to minority health care, it states, “…60 percent of the agency’s core measures did not show any improvement, and 40 percent were getting worse, the agency reported (pg. 2).” The core measures are not further discussed. It could be beneficial to discuss the core measures that were getting worse, as this could be helpful in stating more clear and specific policy recommendations. It would also be interesting to know if whites achieved 100 percent of the agency’s core measures. If they did not, I would recommend comparison to their recorded percentage, in an effort not to skew statistics.
In Exhibit 1, the graph of disparities in life expectancy by age 25, the bars on the graph seem to indicate that Hispanics have a higher life expectancy than whites (pg. 3). After being told they have worse health and care, even if this information is accurate, it does little to build the case that minorities are in need of health care reform. It is not a good example of the disparities being highlighted in the brief, and would be better replaced with another graphic.
Exhibit 2 adds great value to the text by exhibiting the percentage of elderly black patients treated in hospitals with high-cost with low-quality (pg. 4). I recommend adding discussion on the qualities of the nation’s “best” hospitals and better define how the hospitals are ranked. Analogous to school rankings based on test scores, hospitals may appear to have a better score due to serving higher privilege and healthier patients. If this is not the case, a recommendation could be to improve the nation’s “worst” hospitals with qualities of the “best” hospitals, or to emphasize the strategic placement of new hospitals in more rural settings.
In a 2008 survey of physicians, physicians were not confident they could provide high-quality care to Hispanic/Latino patients due to difficulty communicating, limited time spent with patients, and non-adherence to treatment (pg. 5). Empowering clinicians to provide high-quality care is essential. Diversifying the health care workforce is critically important (pg. 3), and an additional recommendation could be an increase in the number of translators available in the health care setting, along with wider acceptance of traditional medicine practices.
I commend the authors for using appropriate tone, language, and style for their intended audience. The problem is clearly stated and backed with evidence. In comparison to the evidence offered, I would encourage the authors to be more specific in the current policy and policy recommendations offered. Given the magnitude of facts presented, the policy maker is likely left caring and knowledgeable about the main contextual issues, but unsure of their next action step. In several of the policy recommendations, the authors use the word ‘attention’, which seems to lack action. Offering specifics for how to give attention will better help the policymakers.
The final paragraph of the brief says, “Research to date has shown that even when care disparities are eliminated, stubborn differences may still persist in health outcomes…More research is needed to figure out why these disparities persist even when care is more equal (pg. 6).” This paragraph seemed to challenge all other means already mentioned in their brief by which minorities can have worse health: stress, lead exposure, education, access to healthy foods, means for a healthy life style, etc. The paper extensively addresses health versus care, but seems to disregard the relationship between the two in the last paragraph. I encourage the authors to re-consider or clarify this policy recommendation based off their original intent.
Finally, in an effort to bring the evidence presented full circle, I would include mention to improving sanitary and climate conditions from industrial pollution as an additional policy topic. Evidence was provided for this, but it never became necessary in the development of a policy recommendation.