Healthcare system interventions for inequality in quality: corrective action through evidence-based medicine

Racial differences in the use of diagnostic and therapeutic services have an impact on outcomes in patients with chronic kidney disease. Important contributors to these racial disparities are inadequate insurance, poor access to health services' networks, and overt prejudice or subconscious bias. The use of an appropriate dose of hemodialysis is a fundamental health intervention for end-stage renal disease, which can act as a measure of the adequacy of healthcare provision. When the dose of hemodialysis was analyzed by race, the greatest deficiency in care was observed for African Americans, who had a 60% greater likelihood of receiving inadequate dialysis compared with whites. The Centers for Medicare and Medicaid Services (CMS) have developed and implemented evidence-based clinical practice guidelines, designed to improve the services provided by the renal community. This approach positively impacted on dialysis doses received by patients, such that between 1993 and 1997, the percentage of patients receiving a benchmark urea reduction ratio (URR) > or = 65% increased from 43% in 1993 to 72% in 1997. However, the most dramatic improvement was seen among African Americans who had a 92% increase in the proportion of patients achieving a URR > or = 65%. Rather than focusing on who is treated, processes should be adopted to focus on how patients are treated. Increasing the use of evidence-based practices offers strategies aimed at assuring equal treatment for all and encompasses physician accountability, without the need for specific race-based intervention programs.