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

Precision emergency medicine in health care delivery and access: Framework development and research priorities

BACKGROUND

The integration of precision emergency medicine (EM) into our conceptualization of the health care system affords the opportunity to improve health care access, delivery, and outcomes for patients. As part of the Society for Academic Emergency Medicine (SAEM) Consensus Conference, we conducted a rapid literature review to characterize the current state of knowledge pertaining to the intersection of precision EM (defined as the use of big data and technology to deliver acute care for individual patients and their communities) with health care delivery and access. We then used our findings to develop a proposed conceptual model and research agenda.

METHODS

We completed a rapid review of the existing literature on the utilization of big data and technology to ensure and enhance access to acute/unscheduled care for individual patients and their communities. Literature searches were conducted using Ovid MEDLINE, Embase.com, Cochrane CENTRAL via Ovid, and ClinicalTrials.gov in January 2023. Using the identified articles, we determined core domains, developed a framework to guide the conceptualization of precision EM in health care delivery and access, and used these to identify a research agenda.

RESULTS

Of the 815 studies identified for initial screening, 60 underwent full-text review by our technical expert panel and 21 were included in the evaluation. Core domains identified included expedited/personalized prehospital care, delivery to the right level of care, personalized ED care, alternatives to ED care/post-ED care, prediction tools for system readiness, and creation of equitable systems of care. A research agenda with four priority research questions was defined following identification of the core domains.

CONCLUSIONS

Precision EM includes consideration of the health care delivery system as a mechanism for improving access to emergency care using data-driven strategies. This provides a unique opportunity to use data and technology to advance systems of care while also centering patients, communities, and equity in these advances.

Understanding racial/ethnic disparities in COVID-19 mortality using a novel metric: COVID excess mortality percentage

Prior research on racial/ethnic disparities in COVID-19 mortality has often not considered to what extent they reflect COVID-19-specific factors, versus preexisting health differences. This study examines how racial/ethnic disparities in COVID-19 mortality vary with age, sex, and time period over April-December 2020 in the United States, using mortality from other natural causes as a proxy for underlying health. We study a novel measure, the COVID excess mortality percentage (CEMP), defined as the COVID-19 mortality rate divided by the non-COVID natural mortality rate, converted to a percentage, where the CEMP denominator controls (albeit imperfectly) for differences in population health. Disparities measured using CEMP deviate substantially from those in prior research. In particular, we find very high disparities (up to 12:1) in CEMP rates for Hispanics versus Whites, particularly for nonelderly men. Asians also have elevated CEMP rates versus Whites, which were obscured in prior work by lower overall Asian mortality. Native Americans and Blacks have significant disparities compared with White populations, but CEMP ratios to Whites are lower than ratios reported in other work. This is because the higher COVID-19 mortality for Blacks and Native Americans comes partly from higher general mortality risk and partly from COVID-specific risk.

Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review

OBJECTIVE

The objective of this review was to describe how health service and delivery systems in high-income countries define and operationalize health equity. A secondary objective was to identify implementation strategies and indicators being used to integrate and measure health equity.

INTRODUCTION

To improve the health of populations, a population health and health equity approach is needed. To date, most work on health equity integration has focused on reducing health inequities within public health, health care delivery, or providers within a health system, but less is known about integration across the health service and delivery system.

INCLUSION CRITERIA

This review included academic and gray literature sources that described the definitions, frameworks, level of integration, strategies, and indicators that health service and delivery systems in high-income countries have used to describe, integrate, and/or measure health equity. Sources were excluded if they were not available in English (or a translation was not available), were published before 1986, focused on strategies that were not implemented, did not provide health equity indicators, or featured strategies that were implemented outside the health service or delivery systems (eg, community-based strategies).

METHODS

This review was conducted in accordance with the JBI methodology for scoping reviews. Titles and abstracts were screened for eligibility followed by a full-text review to determine inclusion. The information extracted from the included studies consisted of study design and key findings, such as health equity definitions, strategies, frameworks, level of integration, and indicators. Most data were quantitatively tabulated and presented according to 5 secondary review questions. Some findings (eg, definitions and indicators) were summarized using qualitative methods. Most findings were visually presented in charts and diagrams or presented in tabular format.

RESULTS

Following review of 16,297 titles and abstracts and 824 full-text sources, we included 122 sources (108 scholarly and 14 gray literature) in this scoping review. We found that health equity was inconsistently defined and operationalized. Only 17 sources included definitions of health equity, and we found that both indicators and strategies lacked adequate descriptions. The use of health equity frameworks was limited and, where present, there was little consistency or agreement in their use. We found that strategies were often specific to programs, services, or clinics, rather than broadly applied across health service and delivery systems.

CONCLUSIONS

Our findings suggest that strategies to advance health equity work are siloed within health service and delivery systems, and are not currently being implemented system-wide (ie, across all health settings). Healthy equity definitions and frameworks are varied in the included sources, and indicators for health equity are variable and inconsistently measured. Health equity integration needs to be prioritized within and across health service and delivery systems. There is also a need for system-wide strategies to promote health equity, alongside robust accountability mechanisms for measuring health equity. This is necessary to ensure that an integrated, whole-system approach can be consistently applied in health service and delivery systems internationally.

REVIEW REGISTRATION

DalSpace dalspace.library.dal.ca/handle/10222/80835.

Measuring health equity in the ASEAN region: conceptual framework and assessment of data availability

BACKGROUND

Existing research on health equity falls short of identifying a comprehensive set of indicators for measurement across health systems. Health systems in the ASEAN region, in particular, lack a standardised framework to assess health equity. This paper proposes a comprehensive framework to measure health equity in the ASEAN region and highlights current gaps in data availability according to its indicator components.

METHODS

A comprehensive literature review was undertaken to map out a core set of indicators to evaluate health equity at the health system level. Secondary data collection was subsequently conducted to assess current data availability for ASEAN states in key global health databases, national health accounts, and policy documents.

RESULTS

A robust framework to measure health equity was developed comprising 195 indicators across Health System Inputs and Processes, Outputs, Outcomes, and Contextual Factors. Total indicator data availability equated to 72.9% (1423/1950). Across the ASEAN region, the Inputs and Processes sub-component of Health Financing had complete data availability for all indicators (160/160, 100%), while Access to Essential Medicine had the least data available (6/30, 20%). Under Outputs and Outcomes, Coverage of Selected Interventions (161/270, 59.63%) and Population Health (350/350, 100%) respectively had the most data available, while other indicator sub-components had little to none (≤ 38%). 72.145% (384/530) of data is available for all Contextual Factors. Out of the 10 ASEAN countries, the Philippines had the highest data availability overall at 77.44% (151/195), while Brunei Darussalam and Vietnam had the lowest data availability at 67.18% (131/195).

CONCLUSIONS

The data availability gaps highlighted in this study underscore the need for a standardised framework to guide data collection and benchmarking of health equity in ASEAN. There is a need to prioritise regular data collection for overlooked indicator areas and in countries with low levels of data availability. The application of this indicator framework and resulting data availability analysis could be conducted beyond ASEAN to enable cross-regional benchmarking of health equity.

Racial and Ethnic Disparities in the Observed COVID-19 Case Fatality Rate Among the U.S. Population

Purpose

During the initial 12 months of the pandemic, racial and ethnic disparities in COVID-19 death rates received considerable attention but it has been unclear whether disparities in death rates were due to disparities in case fatality rates (CFRs), incidence rates or both. We examined differences in observed COVID-19 CFRs between U.S. White, Black/African American, and Latinx individuals during this period.

Methods

Using data from the COVID Tracking Project and the Centers for Disease Control and Prevention COVID-19 Case Surveillance Public Use dataset, we calculated CFR ratios comparing Black and Latinx to White individuals, both overall and separately by age group. We also used a model of monthly COVID-19 deaths to estimate CFR ratios, adjusting for age, gender, and differences across states and time.

Results

Overall Black and Latinx individuals had lower CFRs than their White counterparts. However, when adjusting for age, Black and Latinx had higher CFRs than White individuals among those younger than 65. CFRs varied substantially across states and time.

Conclusions

Disparities in COVID-19 case fatality among U.S. Black and Latinx individuals under age 65 were evident during the first year of the pandemic. Understanding racial and ethnic differences in COVID-19 CFRs is challenging due to limitations in available data.

Measuring and Promoting SARS-CoV-2 Vaccine Equity: Development of a COVID-19 Vaccine Equity Index

Purpose: The coronavirus pandemic has created the greatest public health crisis in a century, causing >500,000 deaths in the United States alone. Minoritized and socioeconomically disadvantaged groups have borne a disproportionate burden of severe illness, hospitalization, and death from COVID-19. Recently developed FDA-approved vaccines have been shown to significantly reduce severe COVID-19–related outcomes. Vaccination campaigns have the potential to advance health equity by prioritizing allocation to those at highest risk while striving for herd immunity. Large integrated health systems have been faced with the daunting task of meeting the rapidly evolving needs of diverse patient populations for the provision of population-based testing, treatment, education, and now vaccine distribution. We have designed a COVID-19 vaccine equity index (CVEI) to guide health system vaccination strategy.

Methods: We considered proportion unvaccinated within a health care system. We then used real-time readily available electronic health record (EHR) COVID-19 testing positivity and proportion hospitalized to measure burden of illness by race/ethnicity. We used conditional probability and statistical theory to measure equity for unvaccinated individuals and to derive an index to highlight these inequities for specific subgroups.

Results: We present an illustrative hypothetical example using simulated data for which we calculated the CVEI for non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic patients. In the example, non-Hispanic Black and Hispanic patients had inequitable outcomes.

Conclusion: The index can be widely implemented to promote more equitable outcomes among racial/ethnic groups, reducing morbidity and mortality within the overall population as we pursue the collective goal of herd immunity through mass vaccination.

Disparities In Outcomes Among COVID-19 Patients In A Large Health Care System In California

As the novel coronavirus disease (COVID-19) pandemic spreads throughout the United States, evidence is mounting that racial and ethnic minorities and socioeconomically disadvantaged groups are bearing a disproportionate burden of illness and death. We conducted a retrospective cohort analysis of COVID-19 patients at Sutter Health, a large integrated health system in northern California, to measure potential disparities. We used Sutter's integrated electronic health record to identify adults with suspected and confirmed COVID-19, and we used multivariable logistic regression to assess risk of hospitalization, adjusting for known risk factors, such as race/ethnicity, sex, age, health, and socioeconomic variables. We analyzed 1,052 confirmed cases of COVID-19 from the period January 1-April 8, 2020. Among our findings, we observed that compared with non-Hispanic white patients, non-Hispanic African American patients had 2.7 times the odds of hospitalization, after adjustment for age, sex, comorbidities, and income. We explore possible explanations for this, including societal factors that either result in barriers to timely access to care or create circumstances in which patients view delaying care as the most sensible option. Our study provides real-world evidence of racial and ethnic disparities in the presentation of COVID-19.