As Call to Address Disparities Grows Louder, Prescriptions for Improvement Emerge
Frontline providers are well aware disparities exist. Many are confronted with the consequences daily, as patients from disadvantaged communities present with problems that might have been prevented with earlier or better-quality care. However, recently suggested because of the hectic pace of busy EDs, emergency providers may be susceptible to letting bias seep into their decision-making. Thus, researchers contended it is important for emergency clinicians to be aware of potential biases and how they contribute to inequities.1
Confronting racism and bias is difficult, but prescriptions for improvement are beginning to emerge. For example, the American Medical Association (AMA) unveiled a toolkit designed to help organizations start toward meaningful improvements. It is an outline of actions investigators with experience in this area deem critical to embedding racial and health equity into an organization’s DNA.2
However, Denard Cummings, MPA, one of the authors and the AMA’s director of Equitable Health System Integration, says this pathway is only appropriate for organizations that are motivated to advance racial equity. “It is not for those who aren’t sure,” he says. “It is for the early adopters who are ready to take steps and just don’t know where to start.”
The first step, “Commit as a Health System to Do the Work,” requires organizations to figure out where they stand with respect to racial justice and equity. That means asking many questions, both formally and informally. Be forewarned that discussing issues around racism, justice, and health equity likely will make some people uncomfortable.
From there, identify champions to lead the improvement effort. “By creating an infrastructure and allocating financial resources to this type of an initiative, the organization is far better positioned to create long-term and radical change,” Cummings says. “Advancing racial justice and health equity requires leadership. It also requires the courage to approach this work with genuine respect to facilitate and create safe spaces for difficult conversations ... and to commit to meaningful action.”
In the second step, “Start Shifting Organizational Norms and Practices by Learning About What You Don’t Know,” the authors instruct organizations to develop a shared understanding of racism in medicine. For instance, the toolkit authors highlighted four types of racism that occur in this arena: structural, institutional, interpersonal, and internalized. This step can be carried out through both individual and group learning.
“Organizations can learn from the experiences of others by talking with other leaders and colleagues about the benefits and challenges of beginning this work, and by reading about the experiences of other health systems in advancing health equity and racial justice,” Cummings says.
Eventually, it is important to pursue opportunities to engage with and support patients, community members, and local leaders, especially those from historically marginalized communities. The toolkit includes questions clinicians might ask patients in the exam room (e.g., whether a patient has lost trust in the health system).
Step three, “Get a Handle on Your Data,” concerns the importance of routinely capturing patient and department-level demographic data, such as race, ethnicity, and primary language. The toolkit authors suggest organizations may want to leverage other data, such as sexual orientation and gender identity, to learn about other negative patterns. Organizations also could learn about food insecurity and housing instability, two issues that often fuel health disparities.
Originally developed at Brigham and Women’s Hospital in Boston, the AMA toolkit includes four data categories organizations can use to assess equity and prioritize action: access, transitions, quality of care, and socioeconomic/environmental impact.3 “You focus on these four points that are already being evaluated by a health system, and you begin to embed equities into those areas,” Cummings says.
After collecting data, organizations move to step four, “Develop a Shared, Clear, Compelling Vision and Goals for the Entire System.” Here, organizations should develop a project charter, a document that spells out specific, measurable goals.
“It [identifies] the population that you want to serve, the tools you are going to use, [and] it establishes the way the different players within the project will agree to interact within the scope of the project,” Cummings says.
With a detailed charter in place, the toolkit directs organizations to move to step five, “Launch Targeted Improvement Efforts Across the System.” One example is the Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) trial.4
In that project, researchers sought to eliminate disparities in care between Black and white patients with early-stage breast and lung cancers by addressing barriers that prevented some from completing radiation treatment. To do this, they deployed four interventions: an automatic alert in the electronic medical record to flag any missed appointments or anticipated milestones that were not reached, a nurse navigator who was trained in race-related barriers to help patients surmount barriers flagged by the automatic alerts, a physician champion charged with providing clinicians with equity-related feedback on treatment completion, and regular equity-related training for all staff.
Before these interventions, the five-year survival rate for Black patients with early-stage breast cancer (89%) lagged behind that of white cancer patients (91%). The gap was similar with surviving lung cancer. After intervention implementation, the survival rate for both groups with early-stage breast and lung cancers improved.
ED leaders might use different metrics in their equity work. For example, if racial disparities are observed in the leave-without-being-seen rate or stroke care, EDs can develop interventions to address those gaps. However, Cummings emphasizes the goal of the AMA toolkit is to help organizations ensure their overall patient populations experience the best outcomes.
“The [ACCURE] trial demonstrates that health equity interventions do not only impact the patients from marginalized populations,” Cummings stresses.
The AMA toolkit is just one of several resources health systems can leverage. For example, in May 2021, the AMA unveiled its overall strategic plan for embedding racial justice and enhancing health equity.5 Later this year, the AMA plans to roll out national health equity grand rounds, a lecture series that will feature thought leaders in the equity arena. Cummings notes this series will be followed by workshops designed to help leaders learn how to operationalize equity into their organizations.
In November 2021, The Joint Commission (TJC) issued a Sentinel Event Alert, calling for accredited healthcare organizations to address disparities, indicating such action is “a moral and ethical duty.”6
The alert noted the COVID-19 pandemic has exacerbated disparity gaps, citing data showing Black and Hispanic patients with the virus have experienced nearly three times the hospitalization rate as white patients.7 When combined, these two minority groups experienced more than half the deaths from COVID-19, even though they make up only one-third of the U.S. population.8 The alert also cited multiple other stark disparities in care related to gender, culture, religion, and disabilities.
Considering many of these disparities have been recognized for years, why are healthcare organizations only now making a big push to address equity? “There has previously been no accountability by healthcare leaders to address equity and inclusion. Leadership [teams] have not viewed equity and inclusion as a quality [or] patient safety concern,” observes Ana Pujols McKee, MD, executive vice president; chief medical officer; and chief diversity, equity, and inclusion officer at TJC. “Healthcare leaders have been allowed to not address how racism and bias negatively impact under-represented groups.”
TJC’s alert made several suggestions about how organizations should address equity, many of which echo the steps contained in the AMA’s toolkit. McKee says TJC intends to put more teeth behind equity improvements soon.
“The Joint Commission’s teams are currently working to have requirements reviewed by the field, which is part of our current process, in anticipation that these requirements will be ready for release to our accredited healthcare organizations in 2023,” she explains.
One tip for administrators is to address diversity opportunities within the leadership ranks. “When those who make decisions understand the needs of under-represented groups served in the community, it is more likely that attention to these concerns will occur,” McKee says. “Each organization must determine its best approach to improve diversity. This opportunity also applies to the governing body.”
Although discussions about racism and diversity may make some uncomfortable, it is important leaders ensure workers and patients fully understand what promoting equity really means.
“Some people wrongfully believe that promoting equity will result in them receiving less access to healthcare,” McKee says. “Rather, equity is inclusive, which means all people will receive appropriate healthcare at the right time and not at the expense of any other group. Equity is inclusive, not exclusive; it is not just for under-represented people but for all people.”
REFERENCES
- Gilbert L, Hsu AP, Diaz R, Mishra D. Addressing bias, racism, and disparities in the emergency department. ACEPNow. Dec. 16, 2021.
- American Medical Association. Racial and health equity: Concrete STEPS for health systems.
- Sivashanker K, Duong T, Resnick A, Eapen S. Health care equity: From fragmentation to transformation. NEJM Catalyst. Sept. 1, 2020.
- Manning M, Yongue C, Garikipati A, et al. Overall survival from a prospective multi-institutional trial to resolve black-white disparities in the treatment of early stage breast and lung cancer. Presented at the American Society for Radiation Oncology Annual Meeting. Oct. 25, 2021.
- American Medical Association. The AMA’s strategic plan to embed racial justice and advance health equity.
- The Joint Commission. Sentinel Event Alert 64: Addressing health care disparities by improving quality and safety.
- Centers for Disease Control and Prevention. Disparities in COVID-19-associated hospitalizations.
- Centers for Disease Control and Prevention. Disparities in deaths from COVID-19.
Frontline providers see patients from disadvantaged communities present with problems that might have been prevented with earlier or better-quality care. However, recently suggested because of the hectic pace of busy EDs, emergency providers may be susceptible to letting bias seep into their decision-making. Thus, researchers contended it is important for emergency clinicians to be aware of potential biases and how they contribute to inequities.
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