Launching the Reduction of Peripartum Racial/Ethnic Disparities Bundle: A Quality Improvement Project

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.

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.

Racial disparities in national maternal mortality trends in the United States from 2000 to 2019: a population-based study on 80 million live births

PURPOSE

In the United States (US), deaths during pregnancy and childbirth have increased over the past 2 decades compared to other high-income countries, and there have been reports that racial disparities in maternal mortality have widened. The study objective was to examine recent trends in maternal mortality in the US by race.

METHODS

Our population-based cross-sectional study used data from the Centers for Disease Control and Prevention's 2000-2019 "Birth Data" and "Mortality Multiple Cause" data files from the US to calculate maternal mortality during pregnancy, childbirth, and puerperium across race. Logistic regression models estimated the effects of race on the risk of maternal mortality and examined temporal changes in risk across race.

RESULTS

A total of 21,241 women died during pregnancy and childbirth, with 65.5% caused by obstetrical complications and 34.5% by non-obstetrical causes. Black women, compared with White women, had greater risk of maternal mortality (OR 2.13, 95% CI 2.06-2.20), as did American Indian women (2.02, 1.83-2.24). Overall maternal mortality risk increased during the 20-year study period, with an annual increase of 2.4 and 4.7/100,000 among Black and American Indian women, respectively.

CONCLUSIONS

Between 2000 and 2019, maternal mortality in the US increased, overall and especially in American Indian and Black women. Targeted public health interventions to improve maternal health outcomes should become a priority.

Severe maternal morbidity by race and ethnicity before vs. during the COVID-19 pandemic

PURPOSE

To examine the change in racial disparity in severe maternal morbidity (SMM) during the COVID-19 pandemic and the associations between SARS-CoV-2 infection and SMM.

METHODS

This retrospective cohort study used linked databases of all livebirths delivered between 2018 and 2021 in South Carolina (n = 162,576). Exposures were 1) pre-pandemic and pandemic periods (before vs. March 2020 onwards); 2) SARS-CoV-2 infection, severity, and timing of first infection. Log-binomial regression models were used.

RESULTS

SMM rate was higher among pandemic childbirths than pre-pandemic period (p = 0.06). The risk of SMM among Hispanics was doubled from pre-pandemic to pandemic periods (adjusted relative risk (aRR)= 2.50, 95% CI: 1.27, 4.94). During pre-pandemic, compared to White women, Black women (aRR=1.37, 95% CI: 1.14-1.64), while Hispanics had lower risk of SMM (aRR=0.42, 95% CI: 0.24-0.73). During the pandemic, the Black-White difference in the risk of SMM persisted (aRR=1.24, 95% CI: 1.00-1.54) and Hispanic-White difference in SMM risk became insignificant (aRR=0.85, 95% CI: 0.54-1.34). SARS-CoV-2 infection, its severity, and the late diagnosis were associated with 1.78-5.06 times higher risk of SMM.

CONCLUSIONS

During pandemic, Black-White racial disparity in SMM persisted but the relative pre-pandemic advantage in SMM among Hispanic women over White women disappeared during the pandemic.

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.

Development of a Maternal Equity Safety Bundle to Eliminate Racial Inequities in Massachusetts

OBJECTIVE

The PNQIN (Perinatal-Neonatal Quality Improvement Network of Massachusetts) sought to adapt the Reduction of Peripartum Racial and Ethnic Disparities Conceptual Framework and Maternal Safety Consensus Bundle by selecting and defining measures to create a bundle to address maternal health inequities in Massachusetts. This study describes the process of developing consensus-based measures to implement the PNQIN Maternal Equity Bundle across Massachusetts hospitals participating in the Alliance for Innovation on Maternal Health Initiative.

METHODS

Our team used a mixed-methods approach to create the PNQIN Maternal Equity Bundle through consensus including a literature review, expert interviews, and a modified Delphi process to compile, define, and select measures to drive maternal equity-focused action. Stakeholders were identified by purposive and snowball sampling and included obstetrician-gynecologists, midwives, nurses, epidemiologists, and racial equity scholars. Dedoose 9.0 was used to complete an inductive analysis of interview transcripts. A modified Delphi method was used to reach consensus on recommendations and measures for the PNQIN Maternal Equity Bundle.

RESULTS

Twenty-five interviews were completed. Seven themes emerged, including the need for 1) data stratification by race, ethnicity and language; 2) performance of a readiness assessment; 3) culture shift toward equity; 4) inclusion of antiracism and bias training; 5) addressing challenges of nonacademic hospitals; 6) a life-course approach; and 7) selection of timing of implementation. Twenty initial quality measures (structure, process, and outcome) were identified through expert interviews. Group consensus supported 10 measures to be incorporated into the bundle.

CONCLUSION

Structure, process, and outcome quality measures were selected and defined for a maternal equity safety bundle that seeks to create an equity-focused infrastructure and equity-specific actions at birthing facilities. Implementation of an equity-focused safety bundle at birthing facilities may close racial gaps in maternal outcomes.

Strategies to Promote Maternal Health Equity: The Role of Perinatal Quality Collaboratives

Perinatal quality improvement is a method to increase obstetric safety and promote health equity. Increasing trends of maternal deaths, life-threatening complications of pregnancy, and persistent racial inequities are unacceptable. This Narrative Review examines the role and strategies of perinatal quality initiatives and collaboratives to deliver safe and equitable maternity care and the evidence of demonstrated success. Key strategies to promote maternal equity through perinatal quality include communicating equity as a priority through leadership, leveraging data and enhancing surveillance, engaging in strategic partnerships, engaging community, educating clinicians, and implementing practice recommendations through collaboration.

Postpartum Hemorrhage-Epidemiology, Risk Factors, and Causes

The incidence of postpartum hemorrhage (PPH) is increasing worldwide and in the United States. Coinciding, is the increased rate of severe maternal morbidity with blood transfusion in the United States over the past 2 decades. Consequences of PPH can be life-threatening and carry significant cost burden to the health care system. This review will discuss the current trends, distribution, and risk factors for PPH. Causes of PPH will be explored in detail.

Where's the "Everyday Black Woman"? An intersectional qualitative analysis of Black Women's decision-making regarding HIV pre-exposure prophylaxis (PrEP) in Mississippi

BACKGROUND

Black cisgender women in the U.S. South bear a disproportionate burden of HIV compared to cisgender women in other racial and ethnic groups and in any other part of the US. Critical to decreasing new HIV infections is the improved delivery of pre-exposure prophylaxis (PrEP) for Black cisgender women as it remains underutilized in 2021. Informed by intersectionality, the study sought to characterize the sociostructural influences on Black cisgender women's deliberations about PrEP within the context of interlocking systems of oppression including racism, sexism, and classism.

METHODS

Six focus groups were conducted with 37 Black women residing in Jackson, Mississippi. This sample was purposively recruited to include Black cisgender women who were eligible for PrEP but had never received a PrEP prescription.

RESULTS

Six themes were identified as concerns during PrEP deliberation among Black women: 1) limited PrEP awareness, 2) low perceived HIV risk, 3) concerns about side effects, 4) concerns about costs, 5) limited marketing, and 6) distrust in the healthcare system. Three themes were identified as facilitators during PrEP deliberations: 1) women's empowerment and advocacy, 2) need for increased PrEP-specific education, and 3) the positive influence of PrEP-engaged women's testimonials. Black women shared a limited awareness of PrEP exacerbated by the lack of Black women-specific marketing. Opportunities to support Black women-specific social marketing could increase awareness and knowledge regarding PrEP's benefits and costs. Black women also shared their concerns about discrimination in healthcare and distrust, but they felt that these barriers may be addressed by patient testimonials from PrEP-engaged Black women, empowerment strategies, and directly addressing provider biases.

CONCLUSIONS

An effective response to PrEP implementation among Black women in the South requires developing programs to center the needs of Black women and carry out active strategies that prioritize peer advocacy while reinforcing positive and mitigating negative influences from broader social and historical contexts.