11/13/2015
Quality Improvement
Opportunities to Promote
Health Equity in
Perinatal Outcomes
Women’s Health Symposium:
Removing the Barriers from
Maternal & Infant Health
Disparities
Las Vegas, Nevada
November 7, 2015
Diane Ashton, MD, MPH
VP Health Equity & Deputy Medical
Director
Objectives
• Present a brief background identifying existing racial &
ethnic disparities in perinatal health
• Describe the fundamental elements of quality improvement
needed to address health disparities
• Share a framework to implement quality improvement
interventions addressing health disparities
“Of all the forms of
inequality, injustice in health
care is the most shocking and
Dr. Martin Luther King, Jr.
inhumane”
at the 2 National Convention of the
nd
Medical Committee for Human Rights
on March 25,1966
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What Are Health Disparities?
Unequal burdens in disease, morbidity and
mortality rates experienced by racial and
ethnic groups as compared to the dominant
population
How do Disparities Arise ?
• Differences in cultural, social, political, economic, or
environmental exposures which result in differences in
underlying health status
• Differences in the quality of care received within the health
care delivery system
• Differences in access to health care including preventive and
curative services
Inequality vs. Inequity
Health Disparity = Health Inequality
Refers to a known disparity in health status or access to care
that characterizes a disproportionate burden of disease or
utility of services among persons or groups within a population
Health Inequities
Reflects the social justice lens of defining a disparity that is
avoidable, unjust, and unfair. In essence, a moral value
judgment is attached to the drivers of health inequities
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Equality vs. Equity
Infant Mortality by Maternal
Race/Ethnicity US, 2000 - 2013
11.1
6.0
5.1
Leading Causes of Infant Mortality
US, 2013
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Infant Mortality by Race/Ethnicity
Nevada, 2011-2013 Average
All race categories exclude Hispanics. An infant death occurs within the first year of life.
Source: National Center for Health Statistics, period linked birth/infant death data. Retrieved October
28, 2015, from www.marchofdimes.org/peristats.
Preterm Birth by Maternal Race
Ethnicity US 2007 - 2014
13.2
8.9
Disparity Index – US
2011-2013 Average
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Disparity Index – Nevada
2011-2013 Average
State Preterm Birth Disparity Index
Scores and Rankings, 2011-2013 (Average)
>
Quality Improvement
Quality improvement (QI) is a
multidisciplinary, systems-focused, datadriven method of understanding and
improving the efficiency, effectiveness, and
reliability of health processes and outcomes
of care
- AHRQ
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Linking Disparities to Quality & Safety
Six major aims of health care:
o Safe
• Minorities have more medical errors with
greater consequences
o Effective
• Minorities receive less evidence-based care
o Patient-centered
• Minorities are less likely to provide truly
informed consent
o Timely
• Minorities are more likely to wait for the
same procedure
o Efficient
• Minorities experience more test ordering in
ED due to poor communication, more
readmissions and avoidable rehospitalizations
o Equitable
• No variation in outcomes
Disparities in Maternal Health &
Health Care
• Hospital Factor – minority serving hospitals perform worse than
other hospitals on selected obstetric quality indicators
• Pregnancy related mortality ratio is three to four time higher
for non-Hispanic Blacks v. non-Hispanic whites
• Severe maternal morbidity is 2.1 times higher for non-Hispanic
blacks compared to non-Hispanic whites
• Black and Hispanic women are more likely to:
• Be uninsured
• Obtain late (third trimester) or no prenatal care
• Obtain substandard prenatal care
• Experience an unintended pregnancy – NHB 70%, Hispanic 57%
Metha, CO-ObGyn 2014 Vol 26, No 6
Racial and Ethnic Disparities in
Health Care – A High Value Target
Many sources contribute to disparities –
no one suspect, no one solution
•
•
•
•
Navigation
Communication
Stereotyping
Mistrust
Variations in care and quality,
inefficiencies, costly care and poor
outcomes are the epitome of low-value
care
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IOM Unequal Treatment
Recommendations
• Increase awareness of existence of disparities
• Address systems of care
– Race/ethnicity data collection, quality improvement, evidencebased guidelines, multidisciplinary teams, community outreach
– Improve workforce diversity
– Facilitate interpretation services
• Provider education
– Health Disparities, Cultural Competence, Clinical decision
making
• Patient education (navigation, activation)
• Research
– Promising strategies, identify barriers to eliminating disparities
How Can QI Reduce Disparities
• Increases awareness of the importance of equity in clinical
operations, provider practices, and in achieving best care
• Creates a cultural transformation in which equity is an
essential element of clinical transformation
• Integrates the concept of equity throughout health care
operations and all other dimensions of quality improvement
and health care practices
• Focuses on the elimination of health care inequities
Mayberry, Proc (Bayl Univ Med cent) 2006;19:103-118
Fundamental Elements of QI to
Reduce Health Disparities
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Data & Health Information
Technology
• Automated & standardized collection of race, ethnicity,
language, and socioeconomic data
• Prioritize use of collected data to identify disparities and
tailor QI efforts
• Focus HIT efforts to address fragmented care delivery for
racial and ethnic populations & limited English proficiency
patients
• Develop computerized clinical decision support systems in
clinical areas with significant health care disparities
• Include input from racial & ethnic populations and those with
limited English proficiency in the development of patient HIT
tools
Lopez, Jt Comm J on QI, Oct 2011 Vol. 37 No. 10
Patient Education
Change the knowledge and / or behaviors of patients
to improve their health outcomes
• Raise awareness about health disparities
impacting their community
• Symptom monitoring
• Incentives
• Culturally targeted education and outreach
• Self management and goal setting
Chin, J Gen Intern Med 27(8)
Provider Education
• Increase awareness of racial & ethnic disparities in
health care - Start in medical school
• Provide information identifying the root causes of
disparities
• Incorporate teaching on the impact of patient race,
ethnicity, and culture on clinical decision making
• Adoption and implementation of evidence-based
guidelines
• Provide training to understand and implement
Quality Improvement and Patient Safety activities
• Disparity report cards
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Cultural Sensitivity
• The ability of health care professionals to communicate
effectively and provide high-quality care to patients from
diverse sociocultural backgrounds
• Provides an approach for providers to focus on developing a
set of skills and a framework that allows the clinician to
assess what sociocultural factors might affect a patient’s
care
• IOM Report Unequal Treatment recommends that all health
care providers receive training in cross-cultural
communications as one strategy to address racial/ethnic
disparities
Betancourt, Acad Med. 2010; 85:583-585
Communication
Language
• Qualified bilingual staff
• Contracted interpreter services
• Remote simultaneous translation
• Translated materials
Health Literacy
• Written materials at an eight grade literacy level
• Adopt “Health Literacy Universal Precautions”
• Provide alternatives to written materials
- videos
- recorded messages
- direct conversation
Diversity in Governance and
Leadership
Increase the proportion of underrepresented
minorities in the health care workforce
• Minorities represent 30% of the US population
however, minority students account for
approximately 11.4% of medical school graduates
• Minorities are significantly underrepresented in
academic medicine as faculty or researchers
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Care Coordination
Apply a systems approach to close the equity gap
• Multidisciplinary teamwork
• Collaboration with community-based services
• Utilize Health Information Technology to create
an integrated referral system including patient
and provider reminder systems
• Develop protocols and standardize processes
across providers, medical facilities, and social
services to facilitate reliable communication
• Patient navigators
Loafman, Am J Clin Med, 2009; Vol 6 No2
Partnerships
•
•
•
•
•
•
•
Academic centers
Community health centers
Providers
Social services
Departments of Public Health
QI researchers
Communities
Community Engagement
What impacts the population the most?
• Identify needs inside & outside the hospital walls
– Community health needs assessment & implementation strategy
– Focus groups, interviews, informal communications
• Build community partnerships
– Partner with people with lived experience to create solutions –
requires relationships and trust
– Partner across sectors in a community to improve health
ƒ Engage local stakeholders and organizations outside traditional
health settings such as churches, schools, and social services
agencies
ƒ Community health workers
• Identify resources in the community for referral services
• Media education campaign
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Social Determinants of Health
•
•
•
•
•
•
•
•
•
•
•
•
•
Poverty
Incarceration
Addiction
Chronic stress
Housing status
Immigration status
Food insecurity
Violence
Education
Transportation
Employment and job training
Experiences of discrimination
Access to health care
Determinants of Health
Physical
Environment
10%
Social &
Economic
Factors
40%
Clinical
Services
20%
Health
Behaviors
30%
Physical Environment 10%
Clinical Services 20%
Health Behaviors 30%
Social & Economic Factors 40%
Framework to Implement QI
Interventions
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6 Steps to Reduce Racial & Ethnic
Disparities in Care – A Roadmap
Step 1
1) Recognize disparities and commit to reducing them
a. Stratify performance data by race, ethnicity,
socioeconomic status, and language
b. Provide disparities training for providers and
staff
Chin, J Gen Intern Med 27(8)
Step 2
2) Implement a basic quality improvement structure
and process
a. Create a culture of quality
b. Designate a quality improvement team
c. Establish a quality improvement process
d. Set goals and metrics
e. Select a local champion
Step 3
3) Make equity an integral component of quality
improvement efforts
a. Recognize equity as a cross-cutting dimension
of quality
b. Ensure that disparities efforts are not
marginalized
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Step 4
4) Design the intervention(s)
a. Determine root causes of disparities in
specific context
b. Consider six levels of influence: patient,
provider, microsystem, organization,
community, policy
c. Review existing literature
d. Learn from peer organizations
e. Use evidence-based strategies
f. Consider specific types of interventions
Step 5
5) Implement, evaluate, and adjust the
intervention(s)
a. Consider implementation models such as the
Consolidated Framework for Implementation
Research
b. Consider best practices
c. Evaluate and adjust intervention
Step 6
6) Sustain the intervention(s)
a. Institutionalize the intervention
b. Create a financial model
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Common Perinatal QI Indicators
Maternal
• Eliminating early elective deliveries before 39 weeks
• Antenatal corticosteroids
• Severe maternal morbidity & mortality
• Nulliparous, term, singleton, vertex (NTSV) cesarean birth
• Breastfeeding
Neonatal
• Neonatal abstinence syndrome
• Central line associated bloodstream infection
• Resuscitation & stabilization
-Lu
ACA and Health Equity
• ACA focused on improving access to health care - quality
improvement - community & public health initiatives
• Moves to standardize data collection and reporting by race,
ethnicity, and language
– A fundamental building block of efforts to identify,
understand and reduce disparities
• Provides for health disparities research and prevention
• Moves to increase workforce
diversity and cultural sensitivity
of workforce
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ACA and Reproductive Health
Equity
• Coverage of essential benefits by all insurance plans based on
IOM’s women’s Clinical Preventive Health Services
recommendations
– Contraceptives
– Annual well woman visit
– Domestic violence screening
– Breastfeeding support
– STI screening
– HPV testing
– Gestational diabetes screening
• Expanded insurance coverage
– New insurance exchanges
– Medicaid expansion
Recommended Actions to Reduce
Health Disparities
1. Increase community awareness of disparities as persistent problems
that represent some of the most pressing health challenges in the
U.S.
2. Set priorities among disparities to be addressed at the federal, state,
tribal, and local levels
3. Articulate valid reasons to expend resources to reduce and ultimately
eliminate priority disparities
4. Implement the dual strategy of universal and targeted intervention
strategies based on lessons learned from successes in reducing certain
disparities (e.g., the virtual elimination of disparities in certain
vaccination rates among children)
5. Aim to achieve a faster rate of improvement among vulnerable groups
by allocating resources in proportion to need and a commitment to
closing gaps in health, longevity, and quality of life
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Chapter 10 - Creating equity and decreasing
disparities in perinatal care and outcomes
• Promote equity and care
across the spectrum of
perinatal care
• Improve access to quality
health care services regardless
of patient’s ability to pay
Health Disparities:
A Denial of Freedom
“At the most basic level, health is freedom. It’s the
freedom to go about our daily lives without
experiencing pain. It’s the freedom to live long enough
to achieve our goals and get to know our grandchildren.
It’s the freedom from constant worries about a chronic
condition or accumulating health care bills”
- Former Secretary Kathleen Sebelius
Department of Health and Human
Services
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