Figure 1 presents the overarching conceptual model for understanding disparities in quality of care. This model is designed specifically to reflect a multilevel approach, documenting individual and system-wide factors that may contribute to quality of care along domains delineated by the IOM. The IOM has defined six qualities of care domains: safe, equitable, effective, patient-centered, timely/accessible and efficient care. It regards the overarching quality domain to be equity in care, or care that "does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status"; (Beal et al 2004; IOM 2001). Disparities in care may thus be viewed as care that is not equitable because it varies based on personal characteristics, rather than clinical need. While there is evidence of inequity or disparity based on various personal characteristics, most published reports emphasize race/ethnicity-based disparities in care. The remaining quality domains are defined by the IOM as follows: safe (avoiding injuries to patients from care that is intended to help them); effective (providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit); patient centered (providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions); timely/ accessible(reducing wait times and sometimes harmful delays for both those who receive and those who give care); and efficient (avoiding
The conceptual model presented here suggests relationships between system-level (ecological) and individual-level factors. Because this report focuses on midlife and older adults who are entering or who are already on Medicare, the role of health insurance coverage is key, and thus explicitly addressed in the model. To maximize its applicability, the model is broad based and non-disease-specific. It emphasizes both ecological components (top of Figure 1) and individual components (bottom of Figure 1). The ecological components include the presence of insurance and the organization of care processes under a health care organization or health insurance program, while individual components include sociodemographic factors and health.
Figure 1 illustrates the two levels of components in detail and their relation to IOM domains of quality care. The model has been simplified by separating individual components from ecological level components, though many of these components are interrelated. For example, a health organization/insurance's business practices and care processes may directly influence quality of care (e.g., differences in select Health Effectiveness and Data Information Set [HEDIS®1] outcomes based on gender, race/ethnicity or other factors), or may influence an individual's health status or use of services, which in turn may influence outcomes. Conversely, an individual's health status may also partly determine a health care insurer or organization's business practices and care processes (e.g., managed care plans with a high proportion of individuals in poor health may provide care or recruit members differently from plans with mostly healthy individuals). In this framework, both individual and ecological components may account for quality
The model also shows that personal characteristics—such as age, gender, race/ethnicity or socioeconomic status—are linked with quality of care outcomes. However, even among persons with similar personal characteristics, differences in "exposure"; to other risks at either the personal level (e.g., health risks) or the ecological level (e.g., insured vs. not insured, achieving "universal insurance status"; by turning 65 years of age and being on Medicare vs. having no universal insurance) can influence quality of care. For example, racial/ethnic disparities in care quality among midlife adults (45–64) and older adults (>65) enrolled in health care plans may be influenced by adverse plan care processes and practices, but the deleterious effect of any adverse process or practice may be different for a midlife adult who transitions between uninsured and insured health insurance status (e.g., due to job loss and gain), than for an older adult who has consistent, virtually-universal health insurance coverage via Medicare.
1HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Table 1 provides an example of the current state of quality of care indicators that address IOM domains. It identifies and categorizes key quality indicators, drawn from national databases, into the IOM domains of safe, effective, patient-centered, timely/accessible and efficient care. Equity is the overarching domain, since inequity in care based on personal characteristics may be found among all the other quality domains (e.g., differences in care based on gender may be found among safety and patient-centered quality of care measures). For effectiveness of care measures, specific examples of quality indicators from diabetes and cardiovascular conditions are used. This general categorization approach has been applied in the area of quality indicators for children's health care (Beal et al 2004), but has not been applied to quality indicators for care among older adults. Identifying and categorizing key examples of quality of care indicators for older adults allows a systematic and easier identification of areas requiring additional development efforts. For example, Table 1 illustrates the clear paucity of existing efficiency indicators, while also showing the well-developed body of effectiveness indicators in quality