Disparities in Cancer Care: Equality vs Equity

Today, many healthcare institutions are taking an introspective look at practice to determine the extent to which disparities may exist within their walls. Some know that disparities exist; others may not. However, since the Institute of Medicine’s Crossing the Quality Chasm: A New Health System for the 21st Century report came out in 2001, expressions of opinion that disparities do not exist are few and far between.

Now that the word is out, research is being conducted on many levels to identify these care issues, but is identifying them enough? Sixteen years have been spent identifying the issues, but what has been done to alleviate them? Certainly a start, especially from a nursing perspective, is the development of nurse navigators to assist patients in the healthcare journey. Many hospitals currently use the STEEEP methodology as a means of bringing the challenge of quality care to the forefront.

STEEEP stands for Safety, Timeliness, Effectiveness, Efficiency, Equity, and Patient-centered care. Most, if not all, hospitals base their values on safety, effectiveness, efficiency, and being patient-centered. But how many truly look to provide equitable care to all patients regardless of personal characteristics? And what is the difference between equality and equity for healthcare?

Identifying Patient Needs

The US Centers for Disease Control and Prevention (CDC) refers to inequity and healthcare disparities interchangeably as “types of unfair healthcare differences closely linked to social, economic, or environmental disadvantages that adversely affect groups of people.”¹ Translating the government language, it means that equity is the process and equality is the outcome of the process. Providing the same types of care and the numbers of available resources to all comers does not allow for equitable care. Underlying issues and individual needs of the underserved, uninsured, and underinsured make needs especially individualized and will need to be addressed in a meaningful manner. Reducing these issues is one of the goals of Healthy People 2020.² Some examples of barriers to equitable healthcare include:

Socioeconomics Many patients need care they cannot afford. Some must make choices between paying insurance premiums, co-pays, and co-insurance vs paying for food, housing, or medications. Others have no coverage and may elect to decline needed care altogether, without knowledge of assistance programs that are available.

Transportation If patients are not present, they cannot get the clinical services they need. Barriers include factors such as cost in the setting of limited, reduced, or no income; limited support networks; public transportation (while being immunosuppressed) that requires multiple transfers or hours of time; public transportation that does not drop off near the facility entrance; limited grant funding and/or limited resource options.

Lack of Cultural Humility The extent to which a healthcare system is unable or unwilling to demonstrate that anyone who enters the door is welcome and that staff is prepared to take care of them. People with ethnic and cultural backgrounds that differ from the majority want care that honors their experiences in the world, values who they are and where they’ve come from, without judgement or expectations of conformity. Stated another way, patients should be able to expect that treatment access and options remain consistent despite individual differences.²

So who is responsible for noticing these issues if and when they exist? Disparities or inequities in healthcare provision have been identified as a public health issue, so including public health agencies and programs is one place to begin. There are numerous services within public health. The ones directly involved in care of the oncology patient include identifying community healthcare issues (cancer is usually one of the top 3 in underinsured communities); mobilizing community partnerships to identify and solve barriers to health care; linking people to needed personal services; ensuring the provision of care when services are not available or cost effective for them; and evaluating the effectiveness, accessibility, and quality of personal and population-based services.³ But public health agencies are not at the forefront of patient care. So where else do we look?