EXECUTIVE SUMMARY

The COVID-19 pandemic has exposed the gaping inequities in healthcare access and quality. Healthcare leaders and policymakers are working to correct these problems. They are reaching out to underserved communities to better understand their needs and concerns.

  • A possible solution is targeted universalism, a concept that involves using specific tactics to provide an advantage to those who have been systematically disadvantaged, and then build from there to achieve universal goals.
  • The Institute for Healthcare Improvement has identified five essential steps: collect the right data, identify non-medical social factors that affect clinical care gaps, nurture open discussion about racism and its effects, and form relationships with community partners.
  • Healthcare leaders stress it is not just racial or ethnic disparities that make a difference, but geographic disparities, too — the rural/urban divide.
  • Experts warn failure to address recognized challenges among disadvantaged groups may lead to bigger problems.

If there was any doubt the American healthcare system was riddled with inequities, the COVID-19 pandemic has erased that thinking. Communities of color, low-income populations, and other disadvantaged groups have been much more likely to suffer the consequences of COVID-19, yet quality of care has been harder to access in the neighborhoods where these populations often reside.

These inequities are hardly news to ED providers who have served as a safety net for such individuals for years. However, the pandemic exposed disparities in such broad relief that they can no longer be ignored. The issue of corrective action was high on the agenda at the Institute for Healthcare Improvement’s (IHI) annual forum, which took place virtually in December.

Health system leaders agreed they must act on several fronts to make quality healthcare more accessible to disadvantaged populations. They shared multiple ideas on how clinical and operational players can work together to address this problem.

In his keynote address, IHI President and CEO Kedar Mate, MD, said healthcare leaders must consider how they will respond differently against future threats.

“The challenges laid bare by this virus are significant: Isolation and discoordination of both individuals and systems, inequities at local and global scales, and false choices between our prosperity and our health,” he said.

How might health systems respond? Mate suggested clinical leaders and policymakers consider targeted universalism, a concept first described by University of California, Berkeley law professor john a. powell, JD. The term means society can achieve objectives by using focused tactics that aim to provide an advantage to those who have been systematically disadvantaged.(Editor’s Note: Professor powell does not capitalize his name: http://bit.ly/2NHJZS5.)

The idea, according to Mate, is that when one provides an advantage to marginalized or excluded groups, and then build from there, one can create a system that delivers benefits to all. As examples, Mate noted seat belts were designed to protect children, but have now saved the lives of thousands of adults and children. Further, smoking laws, which were designed to protect flight attendants and then restaurant and bar workers, have reduced tobacco consumption significantly.

Mate wrapped his address around the construct of “curb cuts,” small off-ramps in the curbs that make it easier for wheelchair-users to traverse streets. Mate noted curb cuts are now widely implemented across the country, delivering benefits to not only disabled persons but also women with strollers, delivery personnel, travelers with suitcases, and many others.

These innovations run counter to the belief that when one provides an advantage to one group, it hurts the rest, and that such an advantage is unfair to others, according to Mate. “In fact, by focusing on the most marginalized and excluded, we just might create a system that is, in fact, better for all of us,” he observed.

However, Mate acknowledged this must happen in a society that has become increasingly polarized, a reality that obscures the value of cooperation at a time when that is precisely what is needed. “It has reduced decision-making to ‘either-or’ constructs where someone has to lose instead of seeing the opportunity that might be present in both, and solutions where multiple parties can benefit,” he explained. “Equity, and specifically health equity, is defined as when all people have the opportunity to achieve their full health potential, and no one is disadvantaged from achieving this potential because of their social position.”

Consider Five Essential Steps

How does targeted universalism point to a way forward for healthcare? First, organizations must understand where they are in terms of equity. Several years ago, IHI decided to do just that, taking a closer look at some of the organization’s most successful quality improvement (QI) initiatives focused on patient safety in a variety of clinical areas, including maternal health, tuberculosis, and cancer care.

Judging by the outcomes data, all the QI projects were successful, but IHI wanted to know which patient lives were improved and whether disparities were maintained or widened.

“For most of these projects, we hadn’t collected the required demographic data that would have allowed us to even know the answer. For those projects where we did [have the data], the disparities remained unchanged,” Mate noted.

Consequently, IHI investigators decided to study those organizations that had made good progress in alleviating identified disparities. The results of this endeavor showed these systems had taken five steps:

  • They made equity a strategic priority.
  • They dedicated resources to collect the right data, and leveraged their quality departments to focus on inequity.
  • They endeavored to understand contributing non-medical social factors affecting specific clinical gaps.
  • They spoke about racism and voiced a desire to overcome its lasting effects.
  • They built relationships with community partners, realizing a push for equity required cooperation.

Since then, IHI has established a collaborative, Pursuing Equity, which is based on using the findings as a “theory of action” to improve health equity.2 The collaborative includes several U.S. health systems, along with some in other countries, and the results have been eye-opening, according to Mate.

For example, he noted one Midwest health system found that among patients in its behavioral health (BH) units, patients who spoke English as a second language (ESL) recorded a length of stay (LOS) twice as long as that of English speakers.

“Having made that observation, the system provided simultaneous language translation services, a targeted strategy, and reduced the LOS difference by 82% between the two populations,” Mate reported. “Not only did the ESL speakers have a shorter hospital stay, but the intervention increased the overall capacity of the BH units in the system, which had the universal effect of benefitting all patients in the community.”

In another health system, ED patients presenting with symptoms of stroke recorded a median time-to-clot-busting-thrombolytic-therapy of 33 minutes. However, when the same ED stratified its data by race, investigators found that time for a white patient was 29 minutes and the time for a Black patient was 48 minutes.

“This observation shocked the ED leadership of the system,” Mate said. “Within days of getting this information, they analyzed their core processes and had begun improvement activities with their clinicians.”

Within a month, the disparity observed between white and Black patients had disappeared. Further, investigators also found the overall time, including all patients, from presentation to treatment with clot-busting drugs, declined from 33 minutes to 28 minutes.

The IHI, in conjunction with the John A. Hartford Foundation, the American Hospital Association, and the Catholic Health Association of the United States, has promoted a series of evidence-based practices to deliver better care for seniors.3 “It turns out that while age-friendly healthcare was built and targeted to benefit older adults, it has had the beneficial side effect of helping all patients receive better care,” Mate said.

Establish Goals

To address healthcare inequities, Mate advised leaders to establish universal goals, understanding that some groups have more ground to make up than others.

Second, identify a clinical measure that is important to the organization. For example, an ED might want to study time-to-thrombolytic-treatment for stroke patients, while an obstetrician might want to look at cesarean rates. “Stratify your data by race, ethnicity, and language,” Mate noted. “You will learn something for sure ... and it may invite opportunities to make improvements.”

Finally, to achieve progress, healthcare professionals must take care of themselves and colleagues. “We will need not only the PPE [personal protective equipment] we wear to physically shield us from this virus, but we need the psychological PPE that can safeguard our minds and souls as we work to save as many lives as we can,” Mate said.

Mate warned that under the concept of targeted universalism, failure to address recognized challenges among disadvantaged groups can lead to bigger problems.

“In healthcare, ignoring the disadvantaged and the systems that perpetuate those disadvantages will lead to complications, not only in the health of individuals but in the health of entire nations,” he said. “We are living this now with COVID-19.”

Apply New Tools, Data

In a separate discussion at the IHI forum, Amy Compton-Phillips, MD, noted that while she still cannot provide great answers on how to improve health equity, her system is applying new data sources and tools to understanding what needs to be fixed.

At Renton, WA-based Providence St. Joseph Health, investigators studied the health outcomes of people who were admitted to the hospital, and found no relationship between ethnicity or race and health outcomes.

“The outcomes really were dependent on [what a patient’s] health status was coming in and how sick they were,” said Compton-Phillips, executive vice president and chief clinical officer for Providence. “There was less of an equity effect once [a patient] was in the hospital.”

However, equity effects are much more noticeable in the community. As a result, Providence is looking much more upstream with the use of tools such as the Social Vulnerability Index (SVI), an instrument that considers 15 social factors, using statistical data collected by the U.S. Census Bureau, to gauge how much support specific areas might need in the face of an emergency such as a disease outbreak.4

With information from the SVI, the health system can study whether it has appropriate resources in place, such as enough COVID-19 testing sites, to ensure residents can access the care they need. However, Compton-Phillips noted a robust effort also must involve researching how people eat, their exercise levels, and what kinds of discrimination or elevated stress levels they may experience. “It requires us to work beyond healthcare’s borders to a much broader community, and there is no place like now to start,” she said.

Compton-Phillips expressed additional concerns about the so-called rural/urban divide. She noted downtown Seattle can may seem like a different country compared to rural areas served by a community access hospital or clinics. “It is not just racial inequities but geographic disparities that make a real difference,” she observed.

The response to the pandemic has shown that one way to address geographic disparities is to more fully leverage telemedicine. Compton-Phillips noted that is how Providence assisted New York City during the pandemic’s early days.

“We couldn’t send physicians out to [New York], but we could do tele-ICU to help. We could do that across state lines because of the relaxation of the rules,” she explained. “We can start matching need to where capacity exists, the ‘moving knowledge, not people’ concept.”

Michael Dowling, president and CEO of New York-based Northwell Health, indicated his organization is working closely with 11 underserved communities as part of a long-term improvement project. Dowling noted an issue of focus right now in these areas is vaccine hesitancy. “Some of these communities are going to have a lot of skepticism toward the [COVID-19] vaccine or any vaccine,” he said. “There are historic reasons for that.”

Going forward, Dowling suggests healthcare organizations must move outside their normal practices to address longstanding inequities. “You’ve got to work with housing, you’ve got to work with empowerment,” Dowling offered. “It is not just [about] delivering medical care itself. A job is the best healthcare antidote that you can actually find ... and as we hire people, that is a focus of ours. You have to broaden the definition of what health is.”

REFERENCES

  1. Haas Institute. Targeted Universalism. Policy & Practice. May 2019.
  2. Institute for Healthcare Improvement. Pursuing Equity.
  3. Institute for Healthcare Improvement. Age-Friendly Health Systems.
  4. Agency for Toxic Substances and Disease Registry. CDC Social Vulnerability Index.