Nearly 2 decades after equity was identified as a key quality health care aim, widespread racial and ethnic disparities in health outcomes persist.1,2 There have been recent pressing calls for equity to be more thoroughly integrated into quality and safety efforts.3,4 In the wake of uprisings against police brutality and systemic racism, Hardeman et al,3 in a 2020 New England Journal of Medicine commentary, recommend that health systems be required to achieve equity in outcomes. Sivashanker and Gandhi4 suggest using stratified data from existing quality and safety infrastructure to bring visibility and transparency to racial inequities in health care institutions and systems. Leveraging quality improvement (QI) data collection to identify disparities by stratifying routinely collected demographic data has been proposed as a key to developing equitable, disparities-targeted QI interventions.5 Equity-focused QI is not a one-size-fits-all approach to improving quality but rather entails interventions designed to improve care for all patients, with emphases on groups experiencing disparate access, care, or outcomes.5 Pediatric hospitals invested in improving equity in patient outcomes are encouraged to conduct QI assessments that account for race to most appropriately tailor improvement efforts.6
One Approach to Improving Transparency: A Pediatric Health Equity Dashboard
In developing a pediatric health equity dashboard (PHED) at our tertiary children’s health care organization with >500 000 patient encounters per year, we aimed to improve organizational transparency with regard to health equity by establishing baseline data on health disparities. Our hospital had tools in place for tracking quality measures and improvement opportunities, but we lacked a systematic way to identify, track, and respond effectively to disparities in processes and patient outcomes. We sought to implement elements of the 2018 National Quality Forum health equity road map7 by leveraging existing quality tracking tools to identify and prioritize opportunities to reduce health disparities at our organization.
For relevant metrics, we included clinic, emergency department, and hospital encounters between January 1, 2019, and December 31, 2019, to establish a 2019 baseline. Metrics are updated on an ongoing quarterly basis; Supplemental Table 1 highlights potential metrics. The 4 initial metrics were procedure-related pain control, well-controlled asthma, combo-10 vaccines, and no-show appointments. We obtained data from the organizational data warehouse, which pulls in structured fields from the electronic health record systems used across the organization (Cerner, eCW, NextGen). Health information management conducts manual audits and uses Physician Compass, a third-party vendor that that applies logic to the Healthcare Effectiveness Data and Information Set measures, for the combo-10 vaccine metric. Data are aggregated and organized in a visual analytic dashboard. Covariates of interest explored with each measure are race and ethnicity and primary language, which are routinely captured in our electronic health record. Notable limitations to validity of race and ethnicity data have been previously described,8 and we continue concurrent QI work to improve reporting.
The dashboard tracks the following for each measure: (1) year-to-date performance in the demographic with the highest number of impacted or “missed” patients (in our population, Black/African American or patients with a preferred language other than English) compared with a control group (white or patients with English language preferred), (2) quarterly trend over the past year and annual trend over 4 years (displayed as linear graphs comparing groups), (3) the annual change in disparity, and (4) the number of missed opportunities in the demographic with the highest number of missed patients (previous year total and current year-to-date rolling).
Significant disparities between white patients and Black/African American patients (the population with the highest number of missed patients) were seen in 2019 (Fig 1) Black/African American patients were less likely to achieve well-controlled asthma (15.1% difference) or to complete routine vaccines by 24 months age (43.1% difference) than white patients. Black/African American patients were more likely to have a no-show ambulatory appointment (16.2% difference) than white patients. After targeted educational interventions for medical assistants in 2018 and 2019, Black/African American patients were more likely to have been offered ways to reduce procedural discomfort (6.4% difference) than white patients.
The alarming disparities in process and health outcome measures that we found are now targets for QI. We have developed a broad stakeholder workgroup to identify and implement changes in vaccinations that may reduce disparities. Drilldowns into which vaccines are being missed as well as locations that patients are seeking care will inform new processes. For example, drive up vaccination options at primary care clinics, conversion of ill-visit appointments to complete well-child checks including vaccinations when appropriate, and potential emergency department screening and administration of vaccinations.
Holding Organizations Accountable Through Measurement
Health equity cannot be achieved without highlighting disparities. Transparency in reporting health inequities is paramount and, in fact, is a sign of progress toward delivering truly high quality (that is to say, equitable) care.4 Exposing inequities means hospitals must be accountable if we are to follow through on promises to improve health equity. In designing our initiative, we knew that the PHED would identify and display areas in which there were inequities in process and/or outcomes for our patients on the basis of their race and ethnicity or primary language. We also recognized that highlighting disparities in patient groups potentially risks detrimental perceptions about or by the group of interest. We have been careful to frame the language and discussion informing and resulting from the PHED instead around accountability, that is, how our system has failed to serve these patients and families and what steps can be taken to improve processes and care. Importantly, we recognize that discussion of disparities often includes uncomfortable but necessary discussions of implicit bias and systemic racism. As an organization, we believe that becoming more open and transparent will continue to facilitate opportunities to better serve our community.
Metric selection and dashboard development are important steps in measuring and highlighting health equity goals. Reducing the disparities that are observed will of course require a great deal of targeted work beyond the identification stage. In addition to continuing to identify new metrics, we are using our dashboard to track performance of QI initiatives. We anticipate that as QI drives reductions in disparities, some metrics will transition to a maintenance monitoring state and be replaced by new metrics with greater improvement opportunity.
Transparency about our own shortcomings as health care institutions is a first step in addressing the implicit, institutional, and structural biases that impact the quality of care received by Black and indigenous patients and patients of color. Ongoing measurement has the potential to drive accountability as we target health disparities in our patient population. Resulting improvements to care (and ultimately also improvements to policies that support and incentivize health equity) benefit of all patients, not just those in identified groups of interest.
We cannot delay in making aggressive changes to reduce disparities in health outcomes. As Hardeman et al3 poignantly note, systemic change can happen quickly when motivated by extreme circumstances like a viral pandemic. First, organizations must systematically measure disparities in process and health outcomes. Second, organizations should be transparent about these opportunities and work with stakeholders to improve and, when necessary, restructure processes altogether to achieve true equity. Third, we must design policies and systems that keep organizations accountable for equitable care delivery. The pandemic of systemic racism and health inequity has gone on far too long and health care organizations must take actionable steps to measure and subsequently reduce disparities in the care we provide to our patients.
We acknowledge the support and efforts of senior leadership and countless stakeholders across the organization in promoting health equity work, particularly, Marc Gorelick, James Burroughs, Emily Chapman, Pamala VanHazinga, Trevor Sawallish, Stuart Winter, Anna Youngerman, Pamela Gigi Chawla, Anupam Kharbanda, Stephen Nelson, Joe Arms, Tom Lang, Tamika Lasege, Alex Heisel, Siman Nuurali, Mike Finch, and Timothy Barnes.
Dr Hester and Ms Nickel conceptualized and designed the study and acquired, analyzed, and interpreted data; Ms Griffin made substantial contributions to concept and data interpretation; and all authors drafted and critically revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.