1. John R. Stone, MD, PhD Center for Health Policy and Medicine johnstone@creighton.edujohnstone@creighton.edu – October 2009

2. John Stone Conflicts 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

3. Alternative Title  Meeting the quality challenge regarding  Race  Ethnicity  Language  SES (Socioeconomic status)

4. 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.

5. 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

6. 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)

7. 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.htm nhdr08.ppt. (Accessed 23Oct2009) http://www.ahrq.gov/qual/qrdr08.htm

8. 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) http://www.ahrq.gov/qual/qrdr08.htm

9. 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.htm nhdr08.ppt. (Accessed 23Oct2009) http://www.ahrq.gov/qual/qrdr08.htm

10. 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) http://www.ahrq.gov/qual/qrdr08.htm

11. AHRQ: Surgery  Better: 2000  2005: “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.pdfhttp://www.ahrq.gov/qual/nhdr08/nhdr08.pdf. (Accessed 23Oct2009)

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

13. Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report. http://www.ahrq.gov/qual/nhdr08/nhdr08.pdfhttp://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) Vs White Vs White

14. Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report. http://www.ahrq.gov/qual/nhdr08/nhdr08.pdfhttp://www.ahrq.gov/qual/nhdr08/nhdr08.pdf. (Accessed 23Oct2009) Composite measure: Medicare surgery patients with postoperative complications, by race, 2004-2006.

15. 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 WAA L- High L- Low Reconstruction % (p <.001) 41344114 Differences “may be related to limited information about the procedure and less access to plastic surgeons.”

16. Surgery to Med Onc Colon 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.

17. Time to Care ED 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

18. 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

19. 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

20.  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

21. Breast Ca Care Surgery & 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.

22. Healthcare Inequalities/Disparities Race & ethnicity:  In the USA, solid evidence documents widespread inequality/disparity of healthcare. 1. Yes 2. No

23. Physician Views: Healthcare Inequalities/Disparities  A significant majority of USA physicians believe that healthcare disparities are a significant problem in the nation. 1. Yes 2. No

24. 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

25. Reasons: Equity Reports  Promote equal and excellent services  Honor respect  Assure justice  Provide humanistic care  Improve relationships with Omaha communities  Increase appeal of CUMC

26. 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)http://www.creightonhospital.com/en-us/cwsapps/qcommitment.aspx

27. CUMC & Healthcare Equality  CUMC provides care of equal quality regardless of race, ethnicity, language, and SES (socioeconomic status) 1. Yes 2. No 3. Uncertain

28. 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. Yes 2. No

29. 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. Yes 2. No

30. CUMC and Equal Care  CUMC assesses whether patients are treated equally regardless of race and ethnicity. 1. Yes 2. No

31. 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. Yes 2. No

32. 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

33. Influences on Quality of Care Race & Ethnicity  Hospital  Region  Specific Providers within hospitals  Hospital resources  Access to specialists  Focus on quality Weinick 2008

34. Hospital Equity Reports Why & What  Healthcare inequalities: R, E, SES, Lang  Assess  Identify  Monitor  (Weinick 2008)

35. Hospital Equity Reports Rationale  Healthcare inequalities: R/E/L  Persist after adjustment  Access  Insurance  SES  Weinick 2008

36. Equity in Healthcare  Needs equally met  Minimized healthcare factors that could produce unequal outcomes  Core element of quality (IOM)  Weinick 2008

37. Equity Report Benefits  Who served  needs  Who needs better care   Capacity to intervene  = care  Track progress  Enhanced community relationships

38. Healthcare Equality: Strategies  Assess  Plan  Educate and train  Assess  Plan  Educate and train  Ongoing  Iterative Weinick 2008

39. Healthcare Equality: Strategies  Leadership investment  Professional involvement  Nurses  Physicians  Social workers  Pharmacists  ….  Community involvement  Horizontal & collaborative Weinick 2008

40. Healthcare Equality: Challenges  Expertise  Will  Resources  Risk See Weinick 2008 on many related points.

41. 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

42. 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

43. 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)

44. 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

45. Equity Implications  “Achieving equity and addressing disparities has implications for quality, cost, risk management, accreditation, and community benefit.”  Betancourt 2009, p. 6.

46. Leadership, Systems, Equity*  Multidisciplinary committee: system reps  RELS data collection  Plan  Develop supporting policies  Identify quality measures (“Disparities dashboard”)  Assess, disseminate, revise *Betancourt 2009

47. Evidence Reviews US 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)http://www.nap.edu/catalog.php?record_id=10260 AHRQ-Agency for Healthcare Research and Quality. “National Healthcare Disparities Report 2008.” (NHDR) p. 62. http://www.ahrq.gov/qual/qrdr08.htm (Accessed 27Sep2009)http://www.ahrq.gov/qual/qrdr08.htm

48. References & Resources Healthcare 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)http://www2.massgeneral.org/disparitiessolutions/resources.html 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) http://www2.massgeneral.org/disparitiessolutions/resources.html  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)http://www2.massgeneral.org/disparitiessolutions/resources.html