SURGERY & “HOSPITAL EQUITY REPORTS”: LEADING THE CURVE IN HEALTHCARE EQUALITY .

John R. Stone, MD, PhDCenter for Health Policy and Medicinejohnstone@creighton.edu – October 2009

John StoneConflicts of Interest & Disclosures

No known conflicts of interest Nothing to disclose

No investments in health-related companies or ventures

No drug or device industry gifts or remuneration

No industry relationships

Alternative Title

Meeting the quality challenge regarding Race Ethnicity Language SES (Socioeconomic status)

Learning Objectives

Regarding healthcare equality:1. Explain why hospitals and

departments should collaborate in developing “equity reports.”

2. Explain key strategies.

3. Explain core challenges.

Policy & Procedure

MGH Policy: “In order to assess and address racial and ethnic disparities on an ongoing basis, all relevant performance improvement data should be collected and stratified by race and ethnicity.”

“Each department’s strategy for meeting this requirement is now discussed at annual meetings between senior hospital leadership and department chairs.”

Weinick 2008

Developing, Coordinating, Communicating

“UW [U of Wisc-Madison] Health has taken a unique approach in creating visibility for efforts related to inequalities within the hospital system, and to coordinating these efforts internally and externally with a variety of different racial and ethnic groups in the community.” (Weinick 2008)

2008 National Healthcare Disparities Report (NHDR)

Disparities persist in

health care quality and

access

Released May 6, 2009

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report. http://www.ahrq.gov/qual/qrdr08.htmnhdr08.ppt. (Accessed 23Oct2009)

NHQR/NHDR Content and Organization

Effectiveness Cancer Diabetes End Stage Renal Disease (ESRD) Heart Disease HIV and AIDS Maternal and Child Health Mental Health and Substance Abuse Nursing Home, Home Health,

and Hospice Care Patient Safety Timeliness Patient Centeredness Access to Health Care Priority Populations

*Also includes a chapter on Efficiency

NHQR*

NHDR

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report. http://www.ahrq.gov/qual/qrdr08.htm. nhdr08.ppt. (Accessed 23Oct2009)

Health Care Quality

Disparities in health care quality are staying the same or increasing

n=number of core measures

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report. http://www.ahrq.gov/qual/qrdr08.htmnhdr08.ppt. (Accessed 23Oct2009)

Disparities in Quality

For Blacks, Asians, American Indians/Alaska Natives, Hispanics, and poor people, disparities stayed the same or increased in at least 60% of quality measures

For Blacks and Asians, disparities decreased in fewer than 20% of quality measures

For AI/ANs, Hispanics, and poor populations, disparities decreased in approximately one-third of quality measures

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report. http://www.ahrq.gov/qual/qrdr08.htmnhdr08.ppt. (Accessed 23Oct2009)

AHRQ: Surgery

Better: 20002005: “appropriate timing of antibiotics”- % “AI/AN adult surgery patients: 52.0% to 80.8% (comparable to Whites)

Good: 1999-2005: Breast Ca I-Iib: Ax node diss/sentinel node bx: rates 75.3 86.5, no inequality

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report. http://www.ahrq.gov/qual/nhdr08/nhdr08.pdf. (Accessed 23Oct2009)

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report. http://www.ahrq.gov/qual/nhdr08/nhdr08.pdf. (Accessed 23Oct2009)

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report. http://www.ahrq.gov/qual/nhdr08/nhdr08.pdf. (Accessed 23Oct2009)

Figure 2.36. Composite measure: Adult surgery patients who received appropriate timing of antibiotics, by race/ethnicity, 2006

Antibiotics 2006 by R/E (timing)

VsWhite

VsWhite

Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report. http://www.ahrq.gov/qual/nhdr08/nhdr08.pdf. (Accessed 23Oct2009)

Composite measure: Medicare surgery patients with postoperative complications, by race, 2004-2006.

 Alderman AK, Hawley ST, Janz NK, et al. Racial and ethnic disparities in the use of postmastectomy breast reconstruction: Results from a population-based study. J Clin Oncol. 2009; JID: 8309333; aheadofprint. (data rounded)

Postmastectomy Breast Reconstruction

W AAL-

High

L-Low

Reconstruction % (p <.001)

41 34 41 14

Differences “may be related to limited information about the procedure and less access to plastic surgeons.”

Surgery to Med OncColon Cancer Significant B/W inequality Worst age 66-70

B: 65.7%, W: 86.3%, Diff 20.6%, 95% CI = 10.7% to 30.4%, P <.001)

Only 50% explainable What role for surgery?

Baldwin LM, Dobie SA, Billingsley K, et al. Explaining black-white differences in receipt of recommended colon cancer treatment. J Natl Cancer Inst. 2005; 97(16):1211-1220.

Time to CareED to Surgery Example: Appendicitis If nonwhite & no private insurance

ED LOS (P < .001) Time to Surgeon’s Dx (P = .0o2)

Small study/single large Acad MC Need more studies.

Bickell NA, Hwang U, Anderson RM, Rojas M, Barsky CL. What affects time to care in emergency room appendicitis patients? Med Care. 2008; 46(4):417-422

Breast Ca

Breslin TM, Morris AM, Gu N, et al. Hospital factors and racial disparities in mortality after surgery for breast and colon cancer. J Clin Oncol. 2009; 27(24):3945-3950

Breast/Colon Ca – Post Hosp Mortality Inequality: 5 year

Breast/Colon Ca – Post Hosp Mortality Inequality: 5 year

Colon Ca

Breslin TM, Morris AM, Gu N, et al. Hospital factors and racial disparities in mortality after surgery for breast and colon cancer. J Clin Oncol. 2009; 27(24):3945-3950

Breast/Colon Ca – Post Hosp Mortality Inequality: 5 year

Breast/Colon Ca – Post Hosp Mortality Inequality: 5 year

Hospital: matters Reasons uncertain-Possibilities

Resources processes of care Multidisciplinary teams Imaging capability Evidence-based adjuvant therapy Insufficient resources to surgery vs ED,

trauma care, ID

Breslin TM, Morris AM, Gu N, et al. Hospital factors and racial disparities in mortality after surgery for breast and colon cancer. J Clin Oncol. 2009; 27(24):3945-3950

Breast Ca CareSurgery & System Freedman RA, Winer EP. Reducing

disparities in breast cancer care: A daunting but essential responsibility. J Natl Cancer Inst. 2008; 100(23):1661-1663JID: 7503089; CON: J Natl Cancer Inst. 2008 Dec 3;100(23):1717-23.

Bickell NA, Shastri K, Fei K, et al. A tracking and feedback registry to reduce racial disparities in breast cancer care. J Natl Cancer Inst (2008) (23):100–1723, 1717.

Healthcare Inequalities/Disparities

Race & ethnicity: In the USA, solid evidence

documents widespread inequality/disparity of healthcare.1. Yes2. No

Physician Views: Healthcare Inequalities/Disparities

A significant majority of USA physicians believe that healthcare disparities are a significant problem in the nation.1. Yes2. No

Beliefs: Healthcare Equality “Just as many people assumed that

they “knew” a hospital provided good quality care before quality measurement became common, many now assume that their hospital provides equal quality of care to all of its patients, regardless of their race, ethnicity, language, or socioeconomic status.”

Weinick 2008

Reasons: Equity Reports

Promote equal and excellent services Honor respect Assure justice Provide humanistic care Improve relationships with Omaha

communities Increase appeal of CUMC

CUMC*“Through our Commitment to Quality we will work to:”

“Provide exceptional clinical care to every patient we serve”

*http://www.creightonhospital.com/en-us/cwsapps/qcommitment.aspx (Accessed 27Sep2009)

CUMC & Healthcare Equality

CUMC provides care of equal quality regardless of race, ethnicity, language, and SES (socioeconomic status)

1. Yes2. No3. Uncertain

Intention and Care

Physicians almost uniformly intend that they personally provide equal and excellent medical care to all patients (regardless of race, ethnicity, and other comparable factors).

1. Yes2. No

Intention and Care

Physicians almost uniformly intend that their institution provide equal and excellent medical care to all patients (regardless of race, ethnicity, and other comparable factors).

1. Yes2. No

CUMC and Equal Care

CUMC assesses whether patients are treated equally regardless of race and ethnicity.

1. Yes2. No

Intention and Outcomes

Regarding race and ethnicity, outcome studies are unnecessary for confidence that race and ethnicity in themselves do not influence quality of care.

1. Yes2. No

Healthcare Equality: Evidence

“Given the pervasiveness of racial and ethnic inequalities nationwide, hospitals cannot assume that they provide equitable care without first examining their data.”

Weinick 2008

Influences on Quality of CareRace & Ethnicity

Hospital Region Specific Providers

within hospitals

Hospital resources Access to

specialists Focus on quality

Weinick 2008

Hospital Equity ReportsWhy & What

Healthcare inequalities: R, E, SES, Lang

Assess Identify Monitor (Weinick 2008)

Hospital Equity ReportsRationale

Healthcare inequalities: R/E/L Persist after adjustment

Access Insurance SES

Weinick 2008

Equity in Healthcare

Needs equally met Minimized healthcare factors that

could produce unequal outcomes Core element of quality (IOM) Weinick 2008

Equity ReportBenefits

Who served needs Who needs better care Capacity to intervene = care Track progress Enhanced community relationships

Healthcare Equality: Strategies

Assess Plan Educate and train Assess Plan Educate and train

Ongoing Iterative

Weinick 2008

Healthcare Equality: Strategies

Leadership investment Professional involvement

Nurses Physicians Social workers Pharmacists ….

Community involvement Horizontal & collaborativeWeinick 2008

Healthcare Equality: Challenges

Expertise Will Resources Risk

See Weinick 2008 on many related points.

Leadership and Change

Who: the leadership Elements of leading change

Urgency Coalition Vision Communicating Empowering action Short-term wins Building on wins Institutionalizing new approaches.

Weinick 2008

Policy & Procedure

MGH Policy: “In order to assess and address racial and ethnic disparities on an ongoing basis, all relevant performance improvement data should be collected and stratified by race and ethnicity.”

“Each department’s strategy for meeting this requirement is now discussed at annual meetings between senior hospital leadership and department chairs.”

Weinick 2008

Developing, Coordinating, Communicating

“UW [U of Wisc-Madison] Health has taken a unique approach in creating visibility for efforts related to inequalities within the hospital system, and to coordinating these efforts internally and externally with a variety of different racial and ethnic groups in the community.” (Weinick 2008)

Key Questions*: Hospital Equity

What existing quality measures can be readily adapted according to RELS?

Can patient satisfaction data be sorted by RELS?

*Weinick 2008

Equity Implications

“Achieving equity and addressing disparities has implications for quality, cost, risk management, accreditation, and community benefit.”

Betancourt 2009, p. 6.

Leadership, Systems, Equity* Multidisciplinary committee: system

reps RELS data collection

Plan Develop supporting policies

Identify quality measures (“Disparities dashboard”)

Assess, disseminate, revise*Betancourt 2009

Evidence ReviewsUS Healthcare Inequality

2002: IOM-Institute of Medicine, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care”

2003-2008: AHRQ-Agency for Healthcare Research and Quality, “National Healthcare Disparities Report (NHDR)”

IOM: http://www.nap.edu/catalog.php?record_id=10260(Accessed 27Sep2009)

AHRQ-Agency for Healthcare Research and Quality. “National Healthcare Disparities Report 2008.” (NHDR) p. 62. http://www.ahrq.gov/qual/qrdr08.htm (Accessed 27Sep2009)

References & ResourcesHealthcare Equity

Betancourt 2009: Betancourt JR, Green AR, King RR, et al. Improving Quality and Achieving Equity: A Guide for Hospital Leaders. The Disparities Solutions Center at Massachusetts General Hospital. (http://www2.massgeneral.org/disparitiessolutions/resources.html, Accessed 26Sep2009)

• Cummings LC, Bennett BA, Boutwell AE, Martinez EL. Assuring HealthCare Quality: A Healthcare Equity Blueprint. National Public Health and Hospital Institute National Association of Public Hospitals and Health Systems. Washington DC, 2008. http://www2.massgeneral.org/disparitiessolutions/resources.html. (Accessed 26Sept2009)

Weinick2008: Robin M.Weinick, Katherine Flaherty, and Steffanie J.Bristol. Creating Equity Reports: A Guide for Hospitals. The Disparities Solutions Center, Massachusetts General Hospital,2008. (http://www2.massgeneral.org/disparitiessolutions/resources.html. (Accessed 26Sept2009)