Health equity audits in general practice: a strategy to reduce health inequalities

Closing the gap on healthcare quality for equity-deserving groups: a scoping review of equity-focused quality improvement interventions in medicine

INTRODUCTION

Quality improvement (QI) efforts are critical to promoting health equity and mitigating disparities in healthcare outcomes. Equity-focused QI (EF-QI) interventions address the unique needs of equity-deserving groups and the root causes of disparities. This scoping review aims to identify themes from EF-QI interventions that improve the health of equity-deserving groups, to serve as a resource for researchers embarking on QI.

METHODS

In adherence with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, several healthcare and medical databases were systematically searched from inception to December 2022. Primary studies that report results from EF-QI interventions in healthcare were included. Reviewers conducted screening and data extraction using Covidence. Inductive thematic analysis using NVivo identified key barriers to inform future EF-QI interventions.

RESULTS

Of 5,330 titles and abstracts screened, 36 articles were eligible for inclusion. They reported on EF-QI interventions across eight medical disciplines: primary care, obstetrics, psychiatry, paediatrics, oncology, cardiology, neurology and respirology. The most common focus was racialised communities (15/36; 42%). Barriers to EF-QI interventions included those at the provider level (training and supervision, time constraints) and institution level (funding and partnerships, infrastructure). The last theme critical to EF-QI interventions is sustainability. Only six (17%) interventions actively involved patient partners.

DISCUSSION

EF-QI interventions can be an effective tool for promoting health equity, but face numerous barriers to success. It is unclear whether the demonstrated barriers are intrinsic to the equity focus of the projects or can be generalised to all QI work. Researchers embarking on EF-QI work should engage patients, in addition to hospital and clinic leadership in the design process to secure funding and institutional support, improving sustainability. To the best of our knowledge, no review has synthesised the results of EF-QI interventions in healthcare. Further studies of EF-QI champions are required to better understand the barriers and how to overcome them.

Uses of Social Determinants of Health Data to Address Cardiovascular Disease and Health Equity: A Scoping Review

Background Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Prior research suggests that social determinants of health have a compounding effect on health and are associated with cardiovascular disease. This scoping review explores what and how social determinants of health data are being used to address cardiovascular disease and improve health equity. Methods and Results After removing duplicate citations, the initial search yielded 4110 articles for screening, and 50 studies were identified for data extraction. Most studies relied on similar data sources for social determinants of health, including geocoded electronic health record data, national survey responses, and census data, and largely focused on health care access and quality, and the neighborhood and built environment. Most focused on developing interventions to improve health care access and quality or characterizing neighborhood risk and individual risk. Conclusions Given that few interventions addressed economic stability, education access and quality, or community context and social risk, the potential for harnessing social determinants of health data to reduce the burden of cardiovascular disease remains unrealized.

From quality improvement to equality improvement projects: A scoping review and framework

Increasing awareness of health disparities has led to proposals for a pay-for-equity scheme. Implementing such proposals requires systematic methods of collecting and reporting health outcomes for targeted demographics over time. This lays the foundation for a shift from quality improvement projects (QIPs) to equality improvement projects (EQIPs) that could evaluate adherence to standards and progress toward health equity. We performed a scoping review on EQIPs to inform a new framework for quality improvement through a health equity lens. Forty studies implemented an intervention after identifying a disparity compared to 149 others which merely identified group differences. Most evaluated race-based differences and were conducted at the institutional level, with representation in both the inpatient and outpatient settings. EQIPs that improved equity leveraged multidisciplinary expertise, healthcare staff education, and developed tools to track health outcomes continuously. EQIPs can help bridge the inequality gap and form part of an incentivized systematic equality improvement framework.

Health equity audits: a systematic review of the effectiveness

OBJECTIVES

The purpose of this systematic review is to explore whether health equity audits (HEAs) are effective in improving the equity of service provision and reducing health inequalities.

DESIGN

Three databases (Ovid Medline, Embase, Web of Science) and grey literature (Opengrey, Google Scholar) were systematically searched for articles published after 2000, reporting on the effectiveness of HEA. Title and abstracts were screened according to an eligibility criteria to identify studies which included a full audit cycle (eg, initial equity analysis, service changes and review). Data were extracted from studies meeting the eligibility criteria after full text review and risk of bias assessed using the ROBINS-I tool.

RESULTS

The search strategy identified 596 articles. Fifteen records were reviewed in full text and three records were included in final review. An additional HEA report was identified through contact with an author. Three different HEAs were included from one peer-reviewed journal article, two published reports and one unpublished report (n=4 records on n=3 HEAs). This included 102 851 participants and over 148 practices/pharmacies (information was not recorded for all records). One study reviewed health equity impacts of HEA implementation in key indicators for coronary heart disease, type 2 diabetes and chronic obstructive pulmonary disease. Two HEAs explored Stop Smoking Services on programme access and equity. All reported some degree of reduction in health inequalities compared with prior HEA implementation. However, impact of HEA implementation compared with other concurrent programmes and initiatives was unclear. All included studies were judged to have moderate to serious risk of bias.

CONCLUSIONS

There is an urgent need to identify effective interventions to address health inequalities. While HEAs are recommended, we only identified limited weak evidence to support their use. More evidence is needed to explore whether HEA implementation can reduce inequalities and which factors are influencing effectiveness.

TRIAL REGISTRATION NUMBER

The study was registered prior to its conduction in PROSPERO (CRD 42020218642).

Measuring Health Equity for Ambulatory Care Sensitive Conditions in a Large Integrated Health Care System: The Development of an Index

Disparities in outcomes for preventive and primary health care services often result when vulnerable patients rely on episodic encounters for emergency services that do not meet their long-term health needs. Understanding health outcomes in socially or economically disadvantaged subgroups is crucial to improving community health, and it requires innovative analytics and dynamic application of clinical and population data. While it is common practice to use proxy indicators, such as quality of life and mortality, when discussing health equity, these have shown limited utility and are rarely applied at a population-level within a health system. Therefore, we designed and implemented an index, calculated as the ratio of observed-to-expected encounters, to identify and quantify health inequalities in health care systems. Providing equitable care, as measured by health outcomes, is analogous to precision medicine applied to social determinants. For health systems, the use of this index will facilitate the development of specially-tailored interventions to address inequity and provides a tool to measure the impact of such programs.

Healthcare Utilization and All-Cause Premature Mortality in Hungarian Segregated Roma Settlements: Evaluation of Specific Indicators in a Cross-Sectional Study

Roma is the largest ethnic minority of Europe with deprived health status, which is poorly explored due to legal constrains of ethnicity assessment. We aimed to elaborate health indicators for adults living in segregated Roma settlements (SRS), representing the most vulnerable Roma subpopulation. SRSs were mapped in a study area populated by 54,682 adults. Records of all adults living in the study area were processed in the National Institute of Health Insurance Fund Management. Aggregated, age-sex standardized SRS-specific and non-SRS-specific indicators on healthcare utilization and all-cause premature death along with the ratio of them (RR) were computed with 95% confidence intervals. The rate of GP appointments was significantly higher among SRS inhabitants (RR = 1.152, 95% CI: 1.136–1.167). The proportion of subjects hospitalized (RR = 1.286, 95% CI: 1.177–1.405) and the reimbursement for inpatient care (RR = 1.060, 95% CI: 1.057–1.064) were elevated for SRS. All-cause premature mortality was significantly higher in SRSs (RR = 1.711, 1.085–2.696). Our study demonstrated that it is possible to compute the SRS-specific version of routine healthcare indicators without violating the protection of personal data by converting a sensitive ethical issue into a non-sensitive small-area geographical analysis; there is an SRS-specific healthcare utilization pattern, which is associated with elevated costs and increased risk of all-cause premature death.

Automated Risk Assessment for Stroke in Atrial Fibrillation (AURAS-AF)--an automated software system to promote anticoagulation and reduce stroke risk: study protocol for a cluster randomised controlled trial

Background

Patients with atrial fibrillation (AF) are at significantly increased risk of stroke. Oral anticoagulants (OACs) substantially reduce this risk, with gains seen across the spectrum of baseline risk. Despite the benefit to patients, OAC prescribing remains suboptimal in the United Kingdom (UK). We will investigate whether an automated software system, operating within primary care electronic medical records, can improve the management of AF by identifying patients eligible for OAC therapy and increasing uptake of this treatment.

Methods/Design

We will conduct a cluster randomised controlled trial, involving general practices using the Egton Medical Information Systems (EMIS) Web clinical system. We will randomise practices to use an electronic software tool or to continue with usual care. The tool will a) produce (and continually refresh) a list of patients with AF who are eligible for OAC therapy - practices will invite these patients to discuss therapy at the start of the trial - and b) generate electronic screen reminders in the medical records of those eligible, appearing throughout the trial. The software will run for 6 months in 23 intervention practices. A total of 23 control practices will manage their AF register in line with the usual care offered. The primary outcome is change in proportion of eligible patients with AF who have been prescribed OAC therapy after six months. Secondary outcomes are incidence of stroke, transient ischaemic attack, other major thromboembolism, major haemorrhage and reports of inappropriate OAC prescribing in the data collection sample - those deemed eligible for OACs. We will conduct a process evaluation in parallel with the randomised trial. We will use qualitative methods to examine patient and practitioner views of the intervention and its impact on primary care practice, including its time implications.

Discussion

AURAS-AF will investigate whether a simple intervention, using electronic primary care records, can improve OAC uptake in a high risk group for stroke. Given previous concerns about safety, especially surrounding inappropriate prescribing, we will also examine whether electronic reminders safely impact care in this clinical area.

Trial registration

http://ISRCTN 55722437