LAST YEAR marked the 30th anniversary of the Report of the Secretary's Task Force on Black and Minority Health.1 This report, known as the Heckler Report (for Margaret M. Heckler, then the secretary of the Department of Health and Human Services [HHS]), documented persistent health disparities that accounted for 60 000 excess deaths each year. For the first time, the federal government acknowledged that eliminating health disparities should be a national priority.

"There [is] a continuing disparity in the burden of death and illness experienced by Blacks and other minority Americans as compared with our nation's population as a whole," Secretary Heckler wrote in that report. "Although our health charts do itemize steady gains in the health status of minority Americans, the stubborn disparity remain[s]-an affront both to our ideals and to the ongoing genius of American medicine."

Yet, health disparities-differences in health outcomes between populations2-continue to vex the US health care system.3 These disparities can be based on race, gender, insurance status, and other factors. Many likely result from a combination of economic and cultural factors. They are confounding and deeply frustrating to health care providers, because they persist despite focused attention on making high-quality care available to all.

The National Healthcare Quality and Disparities Report, or QDR, documents and quantifies these disparities. Mandated by Congress and published annually by the Agency for Healthcare Research and Quality (AHRQ) since 2003, the QDR is the gold standard for measuring national progress in achieving quality goals. The integration of disparities data into the quality report demonstrates our recognition that quality improvement is incomplete until everyone enjoys its benefits. Unfortunately, these data show that some of the inequities the Heckler Report described in 1985 still persist.

NATIONAL QUALITY STRATEGY INTEGRATION AND CHARTBOOKS

The QDR has long been a widely accepted, credible national yardstick gauging how we as a nation are doing in improving quality. But it has evolved over time. It now tracks measures that align with the National Quality Strategy (NQS), which was created under the Affordable Care Act. The NQS seeks to harmonize the American health care quality improvement movement by aligning efforts on a set of consensus-based national priorities and goals for both government and the private sector.4

Three pillars support the NQS: the "triple aims" of better care, more affordable care, and healthy communities (ie, supporting proven interventions to address behavioral, social, and environmental determinants of health). Population health, which focuses on health statuses and outcomes of a group of individuals,5 lies at the center of that third pillar. A central tenet of population health is reducing health disparities among different population groups.

This is why 2 recently published QDR chartbooks6 are of special interest. These chartbooks focus on a specific topic or aspect of care that direct users to information that will help analyze quality trends specific to their needs. AHRQ has published chartbooks that call specific attention to the quality of care given to-and disparities suffered by-blacks and Hispanics. The Chartbook for Health Care for Blacks7 (published in February 2016, to coincide with Black History Month) and the Chartbook on Health Care for Hispanics8 are the first of their kind to focus primarily on quality of care for these communities.

AHRQ created chartbooks for these populations because they are the 2 largest minority populations in the United States and also 2 populations that endure a high degree of disparities. A focus on improving care for black and Hispanic populations will have a strong, lasting impact on improving care for all Americans. These chartbooks compare progress with the goals and priorities set forth in the Heckler Report.

Disparities persist

Fortunately, there is some progress to report. A close examination of last year's report reveals that a few disparities have been eliminated. For instance, black children aged 19 to 35 months received 1 or more doses of the measles-mumps-rubella vaccine at similar rates as other children, compared with 2009, when 88% of black children and 91% of white children received the vaccine. Hispanic adults with obesity received nutrition counseling and advice to eat fewer high-fat foods at similar rates as other adults with obesity, compared with 2004, when 41% of Hispanic adults and 50% of white adults received counseling.

Unfortunately, these are the exception, not the rule. Major disparities remain in quality and safety of care.9-11 Parallel gains in access and quality across groups led to persistence of most disparities. Access remains a problem for black and Hispanic patients, in particular, and there are significant race/ethnicity-related disparities in the quality of care actually received for conditions such as heart failure.

The chartbooks' data lead to the conclusion that while health care quality is improving for blacks, it still lags behind that for other groups. For instance, all measures for infant mortality and maternity care have improved for blacks-but infant mortality remains higher for blacks than it is for whites. Similarly, most measures for cardiovascular disease for blacks showed improvement, but there remains a gap when comparing these measures between blacks and whites.

One area that demands special attention for black patients is mental health care. Suicide prevention and mental health care (including substance use disorder treatment) for blacks are worsening. For instance, the percentage of adolescents receiving treatment of depression was lower for blacks than for whites, and this disparity has not changed over time; in 2013, 30.8% of black adolescents with a "major depressive episode" received treatment of depression, compared with 40.2% for white adolescents.

Meanwhile, disparities in mental health care and diabetes were significant issues for Hispanics, according to the QDR. Most measures of care for cancer and cardiovascular diseases were improving for Hispanics, as were about half of measures for diabetes and maternity care. However, no measures of substance use disorders were improving, and mental health care seemed to be getting worse for Hispanics. These are priorities named in the Heckler Report, and the QDR indicates that we have achieved only mixed results in addressing them.

The Chartbook on Health Care for Hispanics also contains specific information about the unique health care challenges that residents on the US side of the US-Mexico border face. These challenges include access to care, cancer, diabetes, and HIV/AIDS.12 (Much of the information in the Chartbook on Health Care for Hispanics is drawn from the United States-Mexico Border Health Commission, which focuses on the health of residents of both sides of the nearly 2000-mile border. The Commission is currently developing strategic goals under a Healthy Border 2020 initiative).

No conversation about health care disparities is complete without mentioning insurance rates, because access is often one of the most defining disparities. Blacks and Hispanics have traditionally had the least health care coverage in the United States. In this area, the QDR is the bearer of good news. The black uninsurance rate (ie, the rate of blacks who lacked health insurance) was 15.9% in the first half of 2014-barely higher than the overall rate of 15.6%. The rate is much higher for Hispanics-33.2%-but that is an improvement from a previous figure of 40.3%. Under the Affordable Care Act, an additional 2.3 million blacks13 and 4.2 million Hispanics14 have gained health coverage. More Americans are enjoying the benefits of health insurance, indicating that a key component of the Affordable Care Act is working as it was intended.

WHY THE QDR MATTERS TO NURSES

Thirty-one years ago, HHS Secretary Heckler wrote that she hoped the report that now bears her name would "mark the beginning of the end of the health disparity that has, for so long, cast a shadow on the otherwise splendid American track record of ever improving health." The QDR and its chartbooks indicate that that vision is not yet complete. The quality of care overall has improved for blacks and Hispanics, and some disparities have been eliminated-but it is clear we have more work to do.

With trends on more than 250 performance measures compiled from more than 40 data sources, the QDR is a data-rich report. But it is more than a collection of numbers. It is a collection of stories. Behind every statistic is a story of somebody's neighbor, parent, grandparent, or child. In the course of providing care at the bedside, nurses often learn, share, and participate in these stories. Patients confide in nurses. They cry on their shoulders. Patients turn to nurses for help when they are in pain.

As a result, the QDR chartbooks on health for blacks and Hispanics will be especially useful to nurses who work primarily with African American and/or Latino populations, because they will help identify issues that might lead to disparities and call special attention to diseases and conditions that their patients might suffer. Researchers can use them to gain a better understanding of specific populations. Nurse leaders can use them to gain a more complete, contextual understanding of their own patient populations and how they compare with national norms.

The QDR demonstrates that we have made great progress in improving quality in the last decade-but the persistence of disparities means that this progress is uneven. The next step in improving quality should be to focus on disparities in quality as a way to drive improvement more efficiently. Making our national health care system the best that it can be for all requires eliminating disparities and, as nurses know, delivering high-quality care to every patient every time. It also means supporting proven interventions to address behavioral, social, and environmental determinants of health. It means recognizing the value of each individual patient, knowing that that patient is part of a larger whole. This is why AHRQ's work can help renew our focus toward ensuring that each patient we serve reaches his or her highest opportunity for health.

REFERENCES