Does a Rising Tide Lift All Boats?  Pursuing Health Equity in the Era of Quality Improvement

By Allison Cole posted 04-17-2018 09:34


There are well-documented deficiencies in healthcare quality in the U.S.  Health systems and health plans around the country invest millions of dollars in quality improvement efforts to address these deficiencies. Despite this concerted effort, broad quality improvement initiatives have failed to address persistent racial and ethnic disparities in health care. New paradigms of quality improvement, which emphasize measuring and reducing healthcare disparities are critical in addressing this problem.

A large health system recently implemented a new colorectal cancer screening program.  Built on a large body of high quality evidence from published literature, the program includes a centralized staff person who queries our electronic health record system to identify patients overdue for colorectal cancer screening.   The staff person then proactively mails eligible patients a kit to collect and return a stool sample for colorectal cancer screening.  The staff person also monitors mailed and returned kits, follows up with patients and providers about results and reminds patients who do not return kits after the initial mailing.  In the literature, similar programs successfully increase overall rates of colorectal cancer screening.  Yet, the impact of these programs on potential racial and ethnic healthcare disparities within the health system is not to my knowledge measured. Rather, success is demonstrated through changes in the overall colorectal cancer screening rate across the health system. 

In the absence of measurement, health system leaders may assume that all patients benefit equally from quality improvement efforts.  And yet, I encourage researchers and health system leaders to question this assumption. In fact, in observational studies, racial and ethnic disparities in colorectal cancer screening rates are greatest in health systems with higher overall screening rates.  To successfully address racial and ethnic disparities in healthcare, targeted or tailored approaches may be needed.

It is clear that continuing broad quality improvement program implementation at the health system level benefits populations as a whole.  However, lack of measurement of the effect on subgroups will continue to mask the potentially negative impact of these programs on healthcare disparities.  

To address this problem, I suggest that health system evaluation of quality improvement efforts include measurement and reporting of effects across patient race and ethnicity subgroups.  While increasingly common in effectiveness research, these types of subgroup outcomes are less commonly reported in quality improvement evaluations. And if or when we find that our massivequality improvement efforts are failing to address racial and ethnic disparities in healthcare, we must make a call to action that drives a paradigm shift in quality improvement. 

Health system leaders need a body of literature reporting results of evidence-based interventions and their impact on healthcare disparities.  Health systems also need support selecting and implementing those evidence-based interventions that are most likely to address critical healthcare disparities.  We need publicly reported data that allows consumers to compare the healthcare disparities across health systems and a system of reimbursement that incentivizes health systems to reduce measured healthcare disparities.  It is with these changes, that we can finally make progress in achieving health equity.