Addressing Healthcare Disparities: Cultural Competency and Quality Improvement Initiatives

Disparities in health care access and quality of care have been well documented. The Commonwealth Fund's Program on Health Care Disparities aims to improve the overall quality of health care delivered to low-income and minority Americans, and to eliminate racial and ethnic health disparities. The program builds on efforts to improve quality of care overall in the United States, focusing on safety-net hospitals and ambulatory care providers serving large numbers of low-income and minority patients. This article explores the multifaceted nature of healthcare disparities and various approaches to address them, emphasizing the role of cultural competency, quality improvement initiatives, and the importance of medical homes.

Understanding Disparities in Healthcare

While there is broad consensus regarding the existence of racial and ethnic disparities in health care, there is less agreement about the root causes. Primary care physicians who treat a disproportionate share of black and Latino patients provide more charity care, see more patients, depend more heavily on low-paying Medicaid, and earn lower incomes than physicians with largely white patient populations.

Research has shown that minority patients tend to see primary care physicians who have less clinical training, see specialists whose patients have poorer clinical outcomes, and seek care at lower-performing hospitals than do white patients. However, a Commonwealth Fund-supported study found that when minority and white patients seek care at the same hospital, they receive the same standard of care. Minority patients receive the best care when they are treated in hospitals that deliver the highest quality care.

The Role of Medical Homes

Findings showed that racial and ethnic disparities are not immutable. Indeed, the survey found that disparities in access to and quality of care largely disappear when adults have a medical home, insurance coverage, and access to high-quality services and systems of care. systems, in the form of patient reminders, also improve the quality of care for vulnerable patients by promoting higher rates of routine preventive screening.

Cultural Competency Initiatives

To improve performance, the program is supporting Alicia Fernandez, M.D., and Hilary Seligman, M.D., M.S., of the University of California, in their evaluation of a Fund-supported survey instrument-the Patient Assessments of Cultural Competency. This project will expand the scope of a study of diabetes patients at large safety-net hospitals in San Francisco and Chicago. The investigators aim to determine how these patients' diabetes outcomes are affected by patient care experiences and cultural competency in health care delivery.

Nancy Fernandez: A Mental Health Advocate

Nancy Fernandez is a Mental Health Counselor and Addictions Specialist, LCSW-A, LCAS-A. Nancy grew up in Monterrey, Nuevo Leon, Mexico, and moved to Durham, North Carolina at the age of 14. She did her bachelor’s degree in social work at Meredith College.

Quality Improvement Projects

In another project, Jordan Peugh, M.A., of Harris Interactive will conduct a national survey of CEOs at 1,078 federally qualified health care centers-important providers of care to low-income, uninsured, and minority patient populations-to examine the extent to which their organizations possess the systems and capacity needed to achieve high performance. The survey will focus on medical home structures, engagement in quality improvement activities, and workforce capacity.

Linda Cummings, Ph.D., and colleagues from The National Public Health and Hospital Institute, will examine emergency department (ED) throughput in public hospitals-that is, how efficiently patients can be seen, cared for, and appropriately discharged. The team will identify safety-net hospitals that have eased ED overcrowding and improved patient flow. After analyzing the strategies used by the high-performers, they will develop an educational program for 15 public safety-net hospitals that are working to improve ED throughput.

Another study, led by Sara Singer, M.B.A., Ph.D., and Nancy Morgan Kane, M.B.A., D.B.A., of Harvard College will identify governance practices and organizational characteristics (such as ownership or affiliation with a Medicaid managed care plan or primary care clinics) of top safety-net hospitals. They will identify practices that lower-performing hospitals could adopt to raise their financial performance and improve quality of care.

Romana Hasnain-Wynia, Ph.D., and colleagues from the Health Research and Educational Trust, will conduct the first national study of quality in safety-net hospitals, using national data provided by the Hospital Quality Alliance and the American Hospital Association. The project investigators will focus on the treatment provided to patients admitted with myocardial infarction, congestive heart failure, and community-acquired pneumonia. As part of the study, the project team will survey leaders of safety-net hospitals to determine the extent to which their institutions possess organizational systems and capacity, such as electronic health record systems, needed to engage in quality improvement activities.

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Federally funded community health centers (CHCs) are an integral part of the health care safety net for disadvantaged communities. Deborah Gurewich, Ph.D., and Donald S. Shepard, Ph.D., of Brandeis University, will determine the extent to which health centers in three states with large low-income, minority populations (California, Massachusetts, and Texas) provide cost-effective care, identify health centers that provide high-quality care at reasonable costs, and pinpoint the factors that contribute to the success of these high-performing community health centers.

Addressing Heart Failure with Preserved Ejection Fraction

Among patients with heart failure and left ventricular ejection factor of higher than 40%, sacubitril/valsartan treatment compared with standard renin angiotensin system inhibitor treatment or placebo resulted in a significantly greater decrease in plasma N-terminal pro-brain natriuretic peptide levels at 12 weeks but did not significantly improve 6-minute walk distance at 24 weeks.

Background on Heart Failure

Epidemiology of heart failure. Heart failure with preserved ejection fraction.

Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. Irbesartan in patients with heart failure and preserved ejection fraction. Spironolactone for heart failure with preserved ejection fraction.

Internationalization of Education

Developing Cultural and Global Competencies

A National Framework for Developing Cultural and Global CompetenciesHeather Ward, American Council on Education; Mohamed Abdel-Kader, Independent Consultant; Darla K. Deardorff, AIEAHandout AIEA Strategic Issues Committee Shares a Framework of Strategic IssuesSusan Bender, University of Idaho; Lorna Jean Edmonds, Ohio UniversityStrategic Issues: Summary, Analysis, and Priorities Facing International Education Leaders Today Back to the Future: Graduate Education, Expertise and OutcomesNancy Ruther, Yale University; Gil Latz, Indiana University - Purdue University, IndianaAgenda Handout 1 Handout 2 Bridging Divides in the Intercultural ClassroomMark W. Deardorff, Association of International Education AdministratorsHandout 1 Handout 2 Handout 3 Building and Retaining a More Diverse Community of International StudentsC.K. NationalismMark A. Ashwill, Capstone Vietnam; Ryan Buck, Texas State University; Lee D. Partnerships: Strategies and Mechanisms to Access Funding Sources and Increase MobilityChristopher Medalis, International Education Consultant; Nina Lemmens, DAAD; Erica Lutes, Fulbright Belgium, Luxembourg, and SchumanPresentation Handout Focus on the SIO as Scholar: How and Where to Publish your ResearchAmir Reza, Babson College; Robin Matross Helms, American Council on Education; Douglas Proctor, University College DublinPresentation Getting Future Ready: Aligning Institutional Strategies with Emerging TrendsRahul Choudaha, DrEducation; Reitumetse Obakeng Mabokela, University of Illinois at Urbana-Champaign; Cheryl Matherly, Lehigh UniversityPresentation Harnessing Language Schools as University PathwaysDeborah Curtis, Niagara University; David Silva, Salem State University; Benjamin Waxman, InteadPresentation How Much do You Really Know? (WES); Raymond Lutzky, NYU Tandon School of Engineering; Hiroshi Ota, Hitotsubashi UniversityPresentation Institutionalizing Intercultural Competence: Strategies for Broad Integration of New Learning OutcomesJoe Potts, University of Kansas; Esther Gottlieb, Ohio State University; Barbara Kappler, University of Minnesota; David Ayers, Purdue UniversityPresentation Intercultural Strategies for Enhancing Campus Inclusion and Student SuccessDi Hu, interEDGE; Amir Reza, Babson College; Amy McNichols, McDaniel College; Torian Lee, Xavier University of LouisianaPresentation Resources International Alumni: Why Is It So Hard to Develop an Effective Policy?Laura Fernandez, The Ohio State University; Esther Gottlieb, The Ohio State University; Roger Brindley, University of South Florida; Eugene Murphy, Rutgers UniversityPresentations International Higher Education’s Scholar-Practitioners: Bridging Research and PracticeAmir Reza, Babson College; Anthony Ogden, Michigan State University; Bernhard Streitwieser, George Washington UniversityPresentation International Strategic Partnerships: Exploring Emerging Practices to Transcend BoundariesClare Banks, Institute of International Education; Terence W. Miller, Marquette University; Rodolfo Hernandez, The University of Texas at DallasPresentation Internationalization and Quality Assurance in Liberal Arts Education: The Perspective of East Asian InstitutionsMiki Sugimura, Sophia University; Kazuo Kuroda, Waseda University; Mikiko Nishimura, International Christian UniversityPresentation Institutionalizing Intercultural Competence: Strategies for Broad Integration of New Learning OutcomesJoe Potts, University of Kansas; Gifty Ako-Adounvo, Ohio State University; David Ayers, Purdue University; Barbara Kappler, University of MinnesotaPresentation Internationalizing the Faculty: How to Better Prepare Professors for Today’s International ClassroomKarin Fischer, The Chronicle of Higher Education; Jun Liu, Stony Brook University; Charles A. Calahan, Purdue UniversityPresentation Handout Linking Silos: International Educators as Transdisciplinary Bridge BuildersGisela Beaudin, Rollins College; Eric Hartman, Haverford College; Joseph Stanley, Simmons CollegePresentation My Way or the Highway: Navigating the Complexities of International AgreementsKristi Hubbard, Northwestern University; Liz Greenfield, Georgetown University; Elizabeth Decherd, Georgetown University; Tania Lima, King’s College LondonPresentation Navigating Silos, Strategic Plans, and SystemsStephen T. Duke, University of Nebraska; Kristi Hubbard, Northwestern University; Penelope Pynes, University of North Carolina GreensboroPresentation Navigating the Boundaries between Different National Approaches to InternationalizationDouglas Proctor, University College Dublin; Markus Laitinen, University of Helsinki & EAIE; Christopher Johnstone, University of MinnesotaPresentation Organizational Change and the Making of an Internationally Friendly UniversitySherif Barsoum, New York University; Gonzalo Bruce, Boise State University; Eveke de Louw, The Hague University of Applied Sciences; Julie Sinclair, Michigan State UniversityPresentation Partnerships as Tools for Development and Internationalization: Lessons from Universities in Kazakhstan and Central AsiaKadisha Dairova, Nazarbayev UniversityPresentation Summary Post-Election RoundtableSusan Buck Sutton, Bryn Mawr College; Penelope Pynes, University of North Carolina at GreensboroHandout Preparing Interculturally Competent Students in High School: What SIOs Need to KnowClay Hensley, College Board; Paul Sanders, International Baccalaureate Organization; Sherif Barsoum, New York University; Darla K. Montgomery, Wheaton College; Mana Derakhshani, Saint Mary’s CollegePresentation Strategically Identifying, Developing, and Explaining Benefits of International Science CollaborationElizabeth Lyons, National Science Foundation, OISE; Mary Anne Walker, Michigan State University; Kevin Kinser, Penn State UniversityPresentation The Dynamic Diversity of the Asia-Pacific: The Evidence Base for the Impact of Research Universities on Global IssuesChristopher Tremewan, Association of Pacific Rim Universities; Cindy Fan, The University of California, Los Angeles; Dennis Galvan, University of OregonResource The International Dimension of Erasmus+: Strategic Opportunities for SIOsElena Vinci Hytter, Linnaeus University; Camilla Andersson Lundqvist, Linnaeus University; Raimonda Markeviciene, Vilnius UniversityHandout The International Faculty Seminar: Three Institutions, Three Variations on a ModelCraig T. Cobane, Western Kentucky University; Robert McKinna Brown, Virginia Commonwealth University; Addie Cheney, Western Kentucky University; Martha L. Merritt, University of RichmondResource Transcending Boundaries through International Research PartnershipsLisa Bardill Moscaritolo, Pace University; Darbi L. Roberts, Columbia UniversityPresentation Using a Cross-‐Cultural Toolkit to Internationalize Your CurriculumSusan Jagendorf-Sobierajski, SUNY Cobleskill; B. A 24-week, randomized, double-blind, parallel group clinical trial (August 2017-October 2019). Primary end points were change from baseline in plasma NT-proBNP level at week 12 and in the 6-minute walk distance at week 24. Among 2572 randomized patients (mean age, 72.6 years [SD, 8.5 years]; 1301 women [50.7%]), 2240 (87.1%) completed the trial. At baseline, the median NT-proBNP levels were 786 pg/mL in the sacubitril/valsartan group and 760 pg/mL in the comparator group. After 12 weeks, patients in the sacubitril/valsartan group (adjusted geometric mean ratio to baseline, 0.82 pg/mL) had a significantly greater reduction in NT-proBNP levels than did those in the comparator group (adjusted geometric mean ratio to baseline, 0.98 pg/mL) with an adjusted geometric mean ratio of 0.84 (95% CI, 0.80 to 0.88; P < .001). At week 24, there was no significant between-group difference in median change from baseline in the 6-minute walk distance with an increase of 9.7 m vs 12.2 m (adjusted mean difference, -2.5 m; 95% CI, -8.5 to 3.5; P = .42). There was no significant between-group difference in the mean change in the Kansas City Cardiomyopathy Questionnaire clinical summary score (12.3 vs 11.8; mean difference, 0.52; 95% CI, -0.93 to 1.97) or improvement in NYHA class (23.6% vs 24.0% of patients; adjusted odds ratio, 0.98; 95% CI, 0.81 to 1.18).

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International Strategic Partnerships

International Strategic Partnerships: Exploring Emerging Practices to Transcend BoundariesClare Banks, Institute of International Education; Terence W. Miller, Marquette University; Rodolfo Hernandez, The University of Texas at DallasPresentation Internationalization and Quality Assurance in Liberal Arts Education: The Perspective of East Asian InstitutionsMiki Sugimura, Sophia University; Kazuo Kuroda, Waseda University; Mikiko Nishimura, International Christian UniversityPresentation Institutionalizing Intercultural Competence: Strategies for Broad Integration of New Learning OutcomesJoe Potts, University of Kansas; Gifty Ako-Adounvo, Ohio State University; David Ayers, Purdue University; Barbara Kappler, University of MinnesotaPresentation Internationalizing the Faculty: How to Better Prepare Professors for Today’s International ClassroomKarin Fischer, The Chronicle of Higher Education; Jun Liu, Stony Brook University; Charles A. Calahan, Purdue UniversityPresentation Handout Linking Silos: International Educators as Transdisciplinary Bridge BuildersGisela Beaudin, Rollins College; Eric Hartman, Haverford College; Joseph Stanley, Simmons CollegePresentation My Way or the Highway: Navigating the Complexities of International AgreementsKristi Hubbard, Northwestern University; Liz Greenfield, Georgetown University; Elizabeth Decherd, Georgetown University; Tania Lima, King’s College LondonPresentation Navigating Silos, Strategic Plans, and SystemsStephen T. Duke, University of Nebraska; Kristi Hubbard, Northwestern University; Penelope Pynes, University of North Carolina GreensboroPresentation Navigating the Boundaries between Different National Approaches to InternationalizationDouglas Proctor, University College Dublin; Markus Laitinen, University of Helsinki & EAIE; Christopher Johnstone, University of MinnesotaPresentation Organizational Change and the Making of an Internationally Friendly UniversitySherif Barsoum, New York University; Gonzalo Bruce, Boise State University; Eveke de Louw, The Hague University of Applied Sciences; Julie Sinclair, Michigan State UniversityPresentation Partnerships as Tools for Development and Internationalization: Lessons from Universities in Kazakhstan and Central AsiaKadisha Dairova, Nazarbayev UniversityPresentation Summary Post-Election RoundtableSusan Buck Sutton, Bryn Mawr College; Penelope Pynes, University of North Carolina at GreensboroHandout Preparing Interculturally Competent Students in High School: What SIOs Need to KnowClay Hensley, College Board; Paul Sanders, International Baccalaureate Organization; Sherif Barsoum, New York University; Darla K. Montgomery, Wheaton College; Mana Derakhshani, Saint Mary’s CollegePresentation Strategically Identifying, Developing, and Explaining Benefits of International Science CollaborationElizabeth Lyons, National Science Foundation, OISE; Mary Anne Walker, Michigan State University; Kevin Kinser, Penn State UniversityPresentation The Dynamic Diversity of the Asia-Pacific: The Evidence Base for the Impact of Research Universities on Global IssuesChristopher Tremewan, Association of Pacific Rim Universities; Cindy Fan, The University of California, Los Angeles; Dennis Galvan, University of OregonResource The International Dimension of Erasmus+: Strategic Opportunities for SIOsElena Vinci Hytter, Linnaeus University; Camilla Andersson Lundqvist, Linnaeus University; Raimonda Markeviciene, Vilnius UniversityHandout The International Faculty Seminar: Three Institutions, Three Variations on a ModelCraig T. Cobane, Western Kentucky University; Robert McKinna Brown, Virginia Commonwealth University; Addie Cheney, Western Kentucky University; Martha L. Merritt, University of RichmondResource Transcending Boundaries through International Research PartnershipsLisa Bardill Moscaritolo, Pace University; Darbi L. Roberts, Columbia UniversityPresentation Using a Cross-‐Cultural Toolkit to Internationalize Your CurriculumSusan Jagendorf-Sobierajski, SUNY Cobleskill; B. A 24-week, randomized, double-blind, parallel group clinical trial (August 2017-October 2019). Primary end points were change from baseline in plasma NT-proBNP level at week 12 and in the 6-minute walk distance at week 24. Among 2572 randomized patients (mean age, 72.6 years [SD, 8.5 years]; 1301 women [50.7%]), 2240 (87.1%) completed the trial. At baseline, the median NT-proBNP levels were 786 pg/mL in the sacubitril/valsartan group and 760 pg/mL in the comparator group. After 12 weeks, patients in the sacubitril/valsartan group (adjusted geometric mean ratio to baseline, 0.82 pg/mL) had a significantly greater reduction in NT-proBNP levels than did those in the comparator group (adjusted geometric mean ratio to baseline, 0.98 pg/mL) with an adjusted geometric mean ratio of 0.84 (95% CI, 0.80 to 0.88; P < .001). At week 24, there was no significant between-group difference in median change from baseline in the 6-minute walk distance with an increase of 9.7 m vs 12.2 m (adjusted mean difference, -2.5 m; 95% CI, -8.5 to 3.5; P = .42). There was no significant between-group difference in the mean change in the Kansas City Cardiomyopathy Questionnaire clinical summary score (12.3 vs 11.8; mean difference, 0.52; 95% CI, -0.93 to 1.97) or improvement in NYHA class (23.6% vs 24.0% of patients; adjusted odds ratio, 0.98; 95% CI, 0.81 to 1.18).

Legal Education Trends

In the years since the Supreme Court decisions in Students for Fair Admissions v. Harvard and Students for Fair Admissions v. University of North Carolina, law schools have experienced increased scrutiny of their admissions processes at both the federal and (particularly in the case of public institutions) state levels. This increased scrutiny seems to be part of a broader trend in which governments and private organizations have challenged previously accepted norms surrounding legal education and reignited debates about what faculty are allowed to do both inside and outside the classroom.

Public Engagement by Legal Academics

As law professors, we frequently encounter opportunities to spotlight our research and engage in public discourse via op-eds, testimony, amicus briefs, media commentary, podcasts, and more. Should legal academics engage more actively with the public, or does this detract from scholarly and pedagogical commitments? Drawing on their personal experiences, discussants will debate whether public engagement is a civic duty of the academy. The discussion will also consider institutional incentives, public trust in legal expertise, and the responsibilities of scholars in shaping legal narratives beyond the classroom.

The Evolving Professor-Student Dynamic

In recent years, law schools have placed greater emphasis on being student-centered than perhaps they traditionally had. Many view this as a positive development. Yet, professors must now navigate the expectation of caring for students while still upholding standards, maintaining balance between professional obligations and personal life, and establishing their own professional identities. This discussion group focuses on the new professor-student dynamic and its effect on a faculty member’s ability to accomplish their own personal and professional goals.

Remedies and the Law

Realization of substantive rights depends on remedies. Increasing use of emergency dockets places equitable remedies as pivotal from the start of the litigation. The nature and scope of remedies demonstrate what the law honors most from private law to public. Varied remedies are key to advance executive prerogatives or forestall overreaches. We discuss a host of areas, including intellectual property, unjust enrichment, contracts, torts, criminal law, constitutional law, and administrative law. Before equitable or legal remedies may flow, plaintiffs must meet demanding requirements. Judges may also need to consider federalism, separation-of-powers issues, sovereignty, choice of law, and reform statues. This discussion group explores strategies, obstacles, and unifying principles.

Entering the Legal Academy

How can you find your place in the legal academy? Who can you talk to about your questions? This session provides aspiring law teachers an opportunity to gather information and ask questions of experienced law teachers regarding specific issues in entering the academy. This session explores how to research the legal academic job hiring market and position yourself for the job, including how to build experience and prepare your curriculum vita and academic record to compete in the academic market. This session also provides information regarding the core components of an academic’s life: teaching, scholarship, and service.

The Criminalization of Sin

Over about the past 100 years, one can trace the criminalization of a host of activities that the Victoria era societies labelled as sin. Often, regulation was aimed at curtailing pleasure, including sexual pleasure, drug and alcohol use, access to exotic (and often serious) literature, and more. For most of the 20th century, public demands and Supreme Court precedent expanded individual liberty interests.

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