Increasing
g Equity
q y in Health Services:
the Health Care Equity
q y Audit Cycle
y
Dr. Cordell Neudorf
CMHO, Saskatoon Health Region
Assistant Professor, CH&E, U of S
Context: a Population Health Approach
for health system planning and delivery
• Definitions
– Population health approach
– Health equity
• Misalignment of health system mission
statements and goals with resource
allocation structure and program delivery
allocation,
The Life Expectancy
p
y Gap
p
Saskatoon Health Region 1997-2006
Life
e expectan
ncy at birtth in years
s
80
70
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
SHR
78 8 79.0
78.8
79 0 79.3
79 3 79.3
79 3 79.4
79 4 79.8
79 8 79.7
79 7 79.8
79 8 79.9
79 9 79.9
79 9
Core Nhd 74.7 75.4 76.4 75.0 75.0 75.0 74.1 74.4 74.3 73.4
Factors that influence health
Source: Dahlgreen, G. & Whitehead, M. (2006). European strategies for tackling social inequities in health: Levelling up Part 2. World Health
Organization.
Levels of Action
1. Direct delivery of disease prevention and health
promotion services by parts of the system
2. Integration of a population health approach into
all parts of the system to improve health and
h lh
healthcare
equity
i
3. Advocacy and partnership with other sectors and
organizations
i ti
to
t improve
i
health
h lth equity
it andd the
th
social determinants of health
Neudorf, 2012 – in press
Integration into health system
• Common
C
f t
features
off a population
l ti health
h lth approachh:
– Organizational culture with equal emphasis on promoting
health/preventing disease and treating illness
– Invest in activities that reduce inequities
– Intersectoral collaboration and partnerships with community
g p
groups
– Genuine community participation
– Support for sustainable community development
– Data collection that includes ethnicity,
ethnicity deprivation and outcomes
for all health data
– Workforce development to support this braoder population health
Poore M.
Poore,
M JNZMA 2009: 122(1290)
approach
Integration into health system
• Examples of actions that help integration of
a ppopulation
p
health approach:
pp
– Invest in population health analysis capacity
– Introduce healthcare equity audits across the health
system
– Perform health equity impact assessments on healthcare
policy decisions
– Put a population health specialist on your senior team
Neudorf, 2012- in press
Health Care Equity
Mador, 2010
Effective interventions to address health inequity
•
•
•
•
•
•
•
•
•
•
•
•
•
Ensure culturally
E
lt ll safe
f service
i provision
ii
Consider literacy and language diversity for public messaging and materials.
Skill building and interactive components for behavioural interventions.
L
Long
t
term
sustainable
t i bl programming
i in
i communities
iti
Integrate social supports and inclusion of families in health programming
Orientate service-provision within home, school, workplace, and community.
S
Support
hhousing
i initiatives
i ii i
andd opportunities
i i for
f integration
i
i off services
i
Facilitate the formation of multidisciplinary teams, integrated services and
case management for high risk and marginalized populations
Integrate community health workers and lay health workers into the
organization of care, particularly within ethnic and minority communities
Standardize provider care systems to support equitable service provision
Identify and address existing barriers to service which lead to inequities
inequities.
Conduct healthcare equity audits and targeted literature reviews
Develop evaluation frameworks
From Code, J. “Revisiting the Health
Equity Evidence”, SHR PHO, 2012
Health Care Equity Audit Cycle
Measure Impact and
Amend intervention
Problem
(inequity)
and causes
Implement
Intervention
Identify
Evidence Based
Interventions
Involve managers and practitioners
“Equal Service for Equal Need”
Dimensions of Service
– Volume
– Quality
– Uptake
Dimensions of Equity
–
–
–
–
–
Socioeconomic,
Gender ,
RIS,
Age,
Rural : Urban
The Use : Need ratio
Use of service / Need for Care = 1
Measurement Framework for a Comprehensive
View of Health Care Quality in Saskatchewan
HQC 2008
Healthcare Equity Audit: Diabetes
Age
e standardized prevalence rate %
Diabetes is increasing over time
6
5
4
SHR
3
Canada
2
1
0
2001/02
2002/03
2003/04
2004/05
2005/06
2006/07
15
Age
e standardize
ed prevalenc
ce rate %
Variation in diabetes prevalence.
14
12
10
8
6
4
2
0
Male
Female
RIS
Non-RIS
Low
income
Nhds
Middle
Income
Nhds
Affluent Rural SHR
Nhds
16
Urban
Age s
stnd hospita
alization rates
s per 1,000
people w
with diabetes
s
Variations in complications in people
with diabetes
8
6
4
2
0
Acute MyocardiaI
Infarction
Stroke
End Stage Renal
Disease
Low income Nhds
7.6
6.4
6.4
Middle income Nhds
5.1
4.5
1.9
Affluent Nhds
3.1
2.9
1.0
17
Quality of Care for Saskatchewan Diabetics
- 2005/2006
Income
≥ 2 A1C
A1C ≤7%
L Limb
Amputation
Per 1000
Hypo/Hyper
admission
Per 1000
ESRD
Per 1000
tests
%
Lowest
20%
35.1
46.3
4.8
5.4
2.8
Highest
20%
%
42.1
51.5
2.3
3.6
1.6
RIS
31.3
43.6
8
8.2
4.8
Age standardized hospitalization rates per 1,000
1 000 for
diabetics, SHR, 2004/05-2006/07combined
Barriers to Quality Healthcare
Patient
•
•
•
•
•
•
•
Affordability
Family responsibilities
Emotional stress
Demands of work
Language
Lack of awareness
Pre io s bad eexperience
Previous
perience
Service
•
•
•
•
•
Availability of service
Complexity of access
Culturally insensitive services
Discrimination
Clinical
li i l practice
i variation
i i
Health Care Equity Audit: Immunization
Measure Impact and
Amend intervention
Problem
Low Immunisation rates
Core Neighbourhood
Implement Phone based
reminder system for
parents
Lit Review
Of evidence and
best practice
+Parent survey
Healthcare Equity Audit:
Homecare
SHR Home Care clients by deprivation
quintile, percentage and age; 2007-2009
Health Care Equity Audit
S i l procedures
d
Cit Residents)
R id t )
Surgical
( City
Procedures
Analysis
•
•
•
•
•
•
•
•
•
•
•
Cataract
Hysterectomy
Hip Replacement
Knee Replacement
Cardiac revascularization
Back Surgery
C
Caesarean
section
ti
Age specific procedure rates
Age specific readmission rates
Waiting times
Age specific Length of in patient
stay
• % day case
• Populations
• G
Gender
d
• Area of residence
• Cultural background
Eg: Cardiovascular Revascularization
3 year age standardized cardiac
revascularization rates by deprivation
quintile,SHR,2006-2009
A standa
Age
ardized
ra
ates per 1,0
000 >20
years popu
ulation
5.0
Quintile 1
4.0
Quintile 2
30
3.0
Quintile 3
2.0
Quintile 4
1.0
Quintile 5
2006-2009
N = 1587
Ischemic Heart Disease Mortality
Ag
ge standard
dized rate
per 1,,000
population>20years
p
3 year combined age standardized IHD mortality
rate by deprivation quintile,SHR,2006-2008
20
2.0
Quintile 1
1.5
Quintile 2
1.0
Quintile 3
Quintile 4
0.5
Quintile 5
2006-2008
N = 609
Proc
cedure/nee
eds ratio
Procedure needs ratio(Cardiac revasc./AMI) for
males,SHR
1.2
1.0
0.8
Quintile 1
Quintile 2
Q
0.6
0.4
0.2
0.0
Quintile 3
Quintile 4
Quintile 5
Revasc/AMI rate ratio
Procedure/nee
eds ratio
Procedure needs ratio(Cardiac revasc./AMI) by
deprivation quintile for females
1.2
1.0
Quintile 1
0.8
Quintile 2
Q
0.6
Quintile 3
0.4
Quintile 4
02
0.2
Quintile 5
0.0
Revasc/AMI rate ratio
Other Areas for Health Care Equity
q y Audit
Measure Impact and
Amend intervention
Problem
(inequity)
and causes
Intervention to
address inequity
Identify
Evidence Based
Interventions
• Attempted Suicide
• Renal Services
• Others?
Next steps
• Publish framework and develop toolkit and supporting
d
documentation
i based
b d on pilot
il sites
i
• Integration of population health and health equity
approaches into quality improvement and LEAN
initiatives in SHR
• O
Ongoing
go g monitoring
o to g aandd evaluation
eva uat o of
o interventions
te ve t o s
and policy changes for their impact on improving
equity in healthcare and beyond
• Comparative research with other jurisdictions in
Canada and internationally