How to achieve health equity

Integrating equity frameworks into surgical quality improvement and health administrative databases: A narrative review

Ensuring safe, timely, and effective surgery is critical for high-quality healthcare and is the goal of surgical quality monitoring systems. At the heart of these systems are health administrative databases which house patient clinico-demographic information, healthcare processes and outcomes. Through analysis of monitoring systems outputs, we can identify gaps within healthcare delivery, patient experience, and surgical outcomes. However, gaps in our healthcare can only be measured by the variables we collect. Equity stratifiers are sociodemographic descriptors that can identify patient populations who experience differences in health and healthcare that may be considered unjust or unfair. They include age, education, gender, geographic location, income, Indigenous identity, racialized group, and sex at birth. These equity stratifiers represent measurable components of the social determinants of health housed within health administrative databases and allow for standardized analysis and reporting of health inequity. However, not all databases collect these stratifiers - making granular analysis of patient subgroups who may experience health inequity impossible to measure. Moreover, in databases that do collect this information, a wide range in the classification systems used makes for comparisons across jurisdictions challenging. The focus of this narrative review will be to apply the principles of the equity stratifier framework to examine what measures are collected in surgical quality improvement databases, cancer monitoring systems and provincial/state health administrative databases in the United States of America and Canada. The goal of this narrative review is to 1) inform researchers, surgeons, and policymakers of the current landscape of social variables collected within common health administrative databases. 2) Outline the pros and cons of the current collection system. 3) Issue a call to action for policymakers to incorporate health equity frameworks into the collection and reporting of data.

Understanding Contributors to Racial/Ethnic Disparities in Emergency Department Throughput Times: a Sequential Mixed Methods Analysis

BACKGROUND

Ensuring equitable care remains a critical issue for healthcare systems. Nationwide evidence highlights the persistence of healthcare disparities and the need for research-informed approaches for reducing them at the local level.

OBJECTIVE

To characterize key contributors in racial/ethnic disparities in emergency department (ED) throughput times.

DESIGN

We conducted a sequential mixed methods analysis to understand variations in ED care throughput times for patients eventually admitted to an emergency department at a single academic medical center from November 2017 to May 2018 (n=3152). We detailed patient progression from ED arrival to decision to admit and compared racial/ethnic differences in time intervals from electronic medical record time-stamp data. We then estimated the relationships between race/ethnicity and ED throughput times, adjusting for several patient-level variables and ED-level covariates. These quantitative analyses informed our qualitative study design, which included observations and semi-structured interviews with patients and physicians.

KEY RESULTS

Non-Hispanic Black as compared to non-Hispanic White patients waited significantly longer during the time interval from arrival to the physician's decision to admit, even after adjustment for several ED-level and patient demographic, clinical, and socioeconomic variables (Beta (average minutes) (SE): 16.35 (5.8); p value=.005). Qualitative findings suggest that the manner in which providers communicate, advocate, and prioritize patients may contribute to such disparities. When the race/ethnicity of provider and patient differed, providers were more likely to interrupt patients, ignore their requests, and make less eye contact. Conversely, if the race/ethnicity of provider and patient were similar, providers exhibited a greater level of advocacy, such as tracking down patient labs or consultants. Physicians with no significant ED throughput disparities articulated objective criteria such as triage scores for prioritizing patients.

CONCLUSIONS

Our findings suggest the importance of (1) understanding how our communication style and care may differ by race/ethnicity; and (2) taking advantage of structured processes designed to equalize care.

Using rising tides to lift all boats: Equity-focused quality improvement as a tool to reduce neonatal health disparities

Evidence of health disparities affecting newborns abounds. Although quality improvement (QI) methodology is often suggested as a tool to advance health equity, the impact of QI initiatives on disparities is variable. QI work may mitigate, worsen, or perpetuate existing disparities. QI projects designed without an intentional focus on equity promotion may foster intervention-generated inequalities that further disadvantage vulnerable groups. This article reviews disparities in perinatal and neonatal care, the impact of QI on health disparities, and the concept of "Equity-Focused Quality Improvement" (EF-QI). EF-QI differs from QI with an equity lens in that it is action-oriented and centered around equity. EF-QI initiatives purposely integrate equity throughout the fabric of the project and are inclusive, collaborative efforts that foreground and address the needs of disadvantaged populations. EF-QI principles are applicable at every stage of project conception, execution, analysis, and dissemination, and may provide opportunities for reducing disparities in neonatal care.

Equity of access to critical care services in Scotland: A Bayesian spatial analysis

Background

There is increasing evidence that access to critical care services is not equitable. We aimed to investigate whether location of residence in Scotland impacts on the risk of admission to an Intensive Care Unit and on outcomes.

Methods

This was a population-based Bayesian spatial analysis of adult patients admitted to Intensive Care Units in Scotland between January 2011 and December 2015. We used a Besag-York-Mollié model that allows us to make direct probabilistic comparisons between areas regarding risk of admission to Intensive Care Units and on outcomes.

Results

A total of 17,596 patients were included. The five-year age- and sex-standardised admission rate was 352 per 100,000 residents. There was a cluster of Council Areas in the North-East of the country which had lower adjusted admission rates than the Scottish average. Midlothian, in South East Scotland had higher spatially adjusted admission rates than the Scottish average. There was no evidence of geographical variation in mortality.

Conclusion

Access to critical care services in Scotland varies with location of residence. Possible reasons include differential co-morbidity burden, service provision and access to critical care services. In contrast, the probability of surviving an Intensive Care Unit admission, if admitted, does not show geographical variation.

Top ranked hospitals: does diversity inclusion matter?

Purpose

The purpose of this research is to compare the mission statements of the hospitals listed on the 2014 US News & World Report’s Best Hospitals List to investigate the research question, “Are high ranking hospitals (HRH) more likely than low ranking hospitals (LRH) to address cultural diversity in strategic statements?”

Design/methodology/approach

The strategic statements of 44 HRH and 56 LRH were compared using chi-square and Fisher’s exact test.

Findings

While the data do not support the notion that HRHs are more likely than LRHs to address diversity in strategic statements, HRHs are more likely than LRHs to actually devote resources to address the issues of cultural diversity.

Research limitations/implications

The current research is limited to a sample taken from the US News & World Report Best Hospitals. This is not a definitive list, and a multitude of third-party hospital raters exist – each with its own unique metrics.

Practical implications

The results do not show a relationship between a hospital’s mission statement and its ranking in the US News List of Best Hospitals. However, the findings suggest that hospitals that maintain a dedicated diversity manager/office do tend to be higher ranked.

Originality/value

This is the first known investigation of the relationship between the inclusion of diversity in hospital mission statements and hospital rankings. The research suggests that addressing diversity in strategic statements is simply not enough and that dedicated, ground-level resources are necessary to properly impact quality care and third-party ratings.

Global Forum: The Burden of Bone and Joint Infections: A Growing Demand for More Resources

The rate and severity of septic complications following joint replacement surgery and the incidence of posttraumatic infections are projected to increase at a faster pace because of a tendency to operate on high-risk patients, including older patients, patients with diabetes, and patients who are immunocompromised or have comorbidities. Musculoskeletal infections are devastating adverse events that may become life-threatening conditions. They create an additional burden on total health-care expenditures, and can lead to functional impairment, long-lasting disability, or even permanent handicap, with the inevitable social and economic burdens. The scientific community should take a more active role to draw public attention to the plight of hundreds of thousands of people across the globe who experience complications, become disabled, and, in some cases, die, and it should highlight what could be achieved if the global community takes decisive steps to improve access, early detection, and appropriate care. However, mitigating the adverse personal, clinical, and socioeconomic effects of these conditions requires increasing financial resources provided by both governments and funding organizations. Furthermore, a targeted action plan from the providers and the professional societies should be put in place so that the burden created by bone and joint infections is included in the agenda for global health-care priorities.

Movement Advocacy, Personal Relationships, and Ending Health Care Disparities

Deep-rooted structural problems drive health care disparities. Compounding the difficulty of attaining health equity, solutions in clinics and hospitals require the cooperation of clinicians, administrators, patients, and the community. Recent protests over police brutality and racism on campuses across America have opened fresh wounds over how best to end racism, with lessons for achieving health equity. Movement advocacy, the mobilizing of the people to raise awareness of an injustice and to advocate for reform, can break down ingrained structural barriers and policies that impede health equity. However, simultaneously advocates, clinicians, and health care organizations must build trusting relationships and resolve conflict with mutual respect and honesty. Tension is inherent in discussions about racial and ethnic disparities. Yet, tension can be constructive if it forces self-examination and spurs systems change and personal growth. We must simultaneously advocate for policy reform, build personal relationships across diverse groups, and honestly examine our biases.

Few Disparities in Baseline Laboratory Testing After the Diuretic or Digoxin Initiation by Medicare Fee-For-Service Beneficiaries

BACKGROUND

Despite the persistence of significant disparities, few evaluations examine disparities in laboratory testing by race/ethnicity, age, sex, Medicaid eligibility, and number of chronic conditions for Medicare fee-for-service beneficiaries' newly prescribed medications. In Medicare beneficiaries initiating diuretics or digoxin, this study examined disparities in guideline-appropriate baseline laboratory testing and abnormal laboratory values.

METHODS AND RESULTS

To evaluate guideline-concordant testing for serum creatinine and serum potassium within 180 days before or 14 days after the index prescription fill date, we constructed retrospective cohorts from 10 states of 99 711 beneficiaries who had heart failure or hypertension initiating diuretic in 2011 and 8683 beneficiaries who had heart failure or atrial fibrillation initiating digoxin. Beneficiaries initiating diuretics were less likely to have testing if they were non-Hispanic Black (relative risk [RR], 0.99; 95% confidence interval [CI], 0.98-0.99) than non-Hispanic White. Beneficiaries initiating diuretics and beneficiaries initiating digoxin were more likely to have testing if they had multiple chronic conditions relative to 0 to 1 conditions. Beneficiaries initiating diuretics with laboratory values were more likely to have an abnormal serum creatinine value at baseline if they were non-Hispanic Black (RR, 2.57; 95% CI, 1.91-3.44), other race (RR, 2.11; 95% CI, 1.08-4.10), or male (RR, 2.75; 95% CI, 2.14-3.52) or an abnormal serum potassium value if they were aged ≥76 years (RR, 1.29; 95% CI, 1.09-1.51) or male (RR, 1.17; 95% CI, 1.03-1.33).

CONCLUSIONS

Testing rates were consistently high, so there were negligible disparities in guideline-concordant testing of creatinine and potassium after the initiation of digoxin or diuretics by Medicare beneficiaries.

Creating the Business Case for Achieving Health Equity

Health care organizations have increasingly acknowledged the presence of health care disparities across race/ethnicity and socioeconomic status, but significantly fewer have made health equity for diverse patients a true priority. Lack of financial incentives is a major barrier to achieving health equity. To create a business case for equity, governmental and private payors can: 1) Require health care organizations to report clinical performance data stratified by race, ethnicity, and socioeconomic status. 2) Incentivize preventive care and primary care. Implement more aggressive shared savings plans, update physician relative value unit fee schedules, and encourage partnerships across clinical and non-clinical sectors. 3) Incentivize the reduction of health disparities with equity accountability measures in payment programs. 4) Align equity accountability measures across public and private payors. 5) Assist safety-net organizations. Provide adequate Medicaid reimbursement, risk-adjust clinical performance scores for sociodemographic characteristics of patients, provide support for quality improvement efforts, and calibrate cuts to Disproportionate Share Hospital (DSH) payments to the pace of health insurance expansion. 6) Conduct demonstration projects to test payment and delivery system reform interventions to reduce disparities. Commitment to social justice is essential to achieve health equity, but insufficient without a strong business case that makes interventions financially feasible.

Shared Decision Making Among Clinicians and Asian American and Pacific Islander Sexual and Gender Minorities: An Intersectional Approach to Address a Critical Care Gap

Shared decision making (SDM) is a model of patient-provider communication. Little is known about the role of SDM in health disparities among Asian American and Pacific Islander (AAPI) sexual and gender minorities (SGM). We illustrate how issues at the intersection of AAPI and SGM identities affect SDM processes and health outcomes. We discuss experiences of AAPI SGM that are affected by AAPI heterogeneity, SGM stigma, multiple minority group identities, and sources of discrimination. Recommendations for clinical practice, research, policy, community development, and education are offered.