Measuring Equity of Care in Hospital Settings:

From Concepts to Indicators

March 5, 2009

Research TeamCRICH• Gilbert Gallaher• Sophie Kim • Maritt Kirst• Aisha Lofters• Kelly Murphy• Patricia O’Campo• Carlos Quiñonez• Nicole Schaefer-

McDaniel• Ketan Shankardass

Hospital Collaborative Partners

• Alexis Dishaw• Rick Edwards• Linda Gardner• Jim O’Neill• Rosalie Steinberg

Background: The Problem

• Disparities among language, racial and ethnic minority groups have been shown to lead to increased medical errors, prolonged length of stay, avoidable hospitalizations and readmissions, as well as over- and under-utilization of procedures

– Ash and Brandt 2006; Jiang et al. 2005; Rathore et al. 2003; Alexander et al. 1999; Divi et al. 2007, Cohen et al. 2005, Carbone et al. 2003

Background

• Knowledge about how to monitor and report on equity is a relatively new and evolving area

• Measuring equity in hospitals is new in Canada

Momentum for Measuring Equity in Hospitals

• Ontario Ministry of Health and Long-Term Care has identified equity of access to care as a strategic priority

• In 2009, the Toronto Central LHIN for the first time required hospitals to report on equity initiatives

Our Task• At the request of the GTA Hospital

Collaborative on Marginalized Populations, we completed a review of scholarly and grey literature to:

1. Find existing approaches for operationalizingand measuring equity of care in the hospital

2. Assess the applicability of these measures for reducing inequities in care for marginalized populations

Equity and the Hospital Setting

Defining equity

• “Health disparities or inequities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage” (Gardner 2008)

Catchment AreaCatchment Area

HospitalHospital

EDED InIn--PatientPatient

PrimaryHealth Care

Long-TermCare

SocialServices

Hospital’s relationship to health and social services environment

Quality improvement cycle for achieving equity in the hospital

Problem identification via

measurement

Measurement of the magnitude of the

problemContinued

measurement

Evaluation of solution and its effects on the problem

Implementation of solutions

Literature search: Process and rational

Search Strategy

Academic and grey literature

English, 1980s onward

Keywords: “access,” “equity,” “measure,” “hospital,” “healthcare”

Articles4,262 academic219 grey

Articles251 academic111 grey

Master Indicator List

706 indicators

Screened title and abstract

Indicator selection by

principle jurisdiction and

priority population

Final indicator selection: Process and rationale

541 IndicatorsMaster Indicator List

706 indicators

Limited to measures with

some relevance to equity within

hospitals+

Priority populations

Final indicator selection: Process and rationale

10 Indicators

1. Evidence of previous use2. Endorsed3. Feasibility4. Adaptability5. Applicability to equity6. Transferability

706 Indicators Grouped similar concepts and indicators

Good ‘first-step’ indicator for HC/TC LHIN

Indicator Table

Post-operative in-hospital pressure ulcer rateElderly

Lower extremity amputations among patients with DMDiabetes Mellitus

Hours of physical restraint useMental Health

Rate of death within 30 days of hospital admission for AMI

Use of analgesics in ED

Minimally invasive cholecystectomy rate

Perforated appendix rate

Patient satisfactionQuality Of CareProvision of interpretation services

Cultural diversity of hospitalCultural CompetencyTitleDomain

Conclusions & Recommendations

• Equity is an essential component of hospital performance and quality– Institute of Medicine, Agency for Healthcare Research

and Quality, Joint Commission, National Quality Forum are all linking equity with quality of care

• Equity indicators should be selected strategically• Equity measurement in Toronto hospitals is

possible now

Strategies Table

- Labour intensive- Costly

- Ability to specify variables and modes of collection- Ability to collect individual-level data

Individual hospitals change internal data systems to collect socio-demographic information

CHANGE EXISTING HOSPITAL DATA SYSTEMS

- Aggregated socio-demographic data- Limited individual-level data

- Existing infrastructure and expertise- Spreads momentum- Relatively inexpensive

Develop partnershipswith ICES and others to facilitate data linkages and data sharing

LINKING EXISTING DATA

DisadvantagesAdvantagesStrategy

Conclusions & Recommendations

• Any indicator can be a potential measure of equity if stratified by socio-demographic attributes

• Better equity measurement will happen when Toronto hospitals collect patient socio-demographic data– Language, socioeconomic status, race, ethnicity

Conclusions & Recommendations

• Recommendations on action steps to achieve equity in the hospital:– Hospitals should conduct an initial assessment of

data capabilities– Hospitals should start by using existing data, stratified

by socio-demographic characteristics– Hospitals should begin to collect language,

socioeconomic status, race and ethnicity data– Hospitals should monitor equity data over time

• Evaluate, redesign, reevaluate– Hospitals should take action on disparities revealed

through measurement

Quality improvement cycle for achieving equity in the hospital

Problem identification via

measurement

Measurement of the magnitude of the

problemContinued

measurement

Evaluation of solution and its effects on the problem

Implementation of solutions

Using measurement to improve hospital equity

• Expecting Success: Excellence in Cardiac Care– Program piloted by the Robert Wood Johnson

Foundation in 10 hospitals to improve cardiovascular care for African Americans and Latinos

– Hospitals reported on 23 care performance measures stratified by language, race, ethnicity on a monthly basis

– Each hospital designed interventions to ensure patients received full set of recommended care

– After only 2 years, the all-hospital median heart failure Measure of Ideal Care increased from 41 percent to 78 percent

Summary• Equity is a key component of quality; addressing

disparities will help achieve this goal

• Measurement related to equity is possible now in Toronto hospitals

• Any indicator can be a potential measure of equity if stratified by socio-demographic attributes

• Better equity measurement will happen when Toronto hospitals collect patient socio-demographic data– Language, socioeconomic status, race, ethnicity

Discussion