A Roadmap for Promoting Health Equity and Eliminating Disparities: The Four I’s for Health Equity

National Quality Forum
Publication Year: 2017
Patient Need Addressed: Chronic Conditions
Population Focus: Vulnerable/disadvantaged
Type of Literature: Grey


Insights Results

Overview of article

  • This report presents a roadmap for reducing health and healthcare disparities through performance measurement and associated policy levers. There are 4 actions outlined called the “Four I’s for Health Equity” that healthcare stakeholders can employ to reduce disparities: 1) Identify and prioritize reducing health disparities; 2) Implement evidence-based interventions to reduce disparities; 3) Invest in the development and use of health equity performance measures; and 4) Incentivize the reduction of health disparities and achievement of health equity

Methods of article

  • Using the social-ecological model, the committee conducted a literature review to identify effective interventions to reduce disparities
  • There are 5 domains of measurement of health equity measurement that represent the core processes, structures and outcomes that must be assessed (and were used for evaluation) to achieve equity: 1) Access to care; 2) High-quality care; 3) Structure for equity that supports a culture of equity (e.g., policies and procedures that institutionalize values that promote health equity); 4) Culture of equity that recognizes and prioritizes the elimination of disparities; and 5) Partnerships and collaboration with other sectors that influence the health of individuals (e.g., neighborhoods, transportation). Public reporting, transparency and accountability are important tools for advancing health equity as well
  • Subdomains for Collaboration and Partnerships are: 1) Collaboration across health and nonhealth sectors; 2) Community and health system linkages; 3) Build and sustain social capital and social inclusion; and 4) Promotion of public and private policies that advance equity
  • Subdomains for Culture of Equity are: 1) Equity is high priority; 2) Safe and accessible environments for individuals from diverse backgrounds; 3) Cultural competency; and 4) Advocacy for public and private policies that advance equity
  • Subdomains for Structure for Equity: 1) Capacity and resources to promote equity; 2) Collection of data to monitor the outcomes of individuals with social risk factors; 3) Population health management; 4) Systematic community needs assessments; 5) Policies and procedures that advance equity; and 6) Transparency, public reporting and accountability for efforts to advance equity
  • Subdomains for Equitable Access to Care: 1) Availability; 2) Accessibility; 3) Affordability; and 4) Convenience
  • Subdomains for Equitable High-Quality Care are: 1) Person- and family-centeredness; 2) Continuous improvements across clinical structure, process and outcome performance measures stratified by social risk factors; and 3) Use of effective interventions to reduce disparities in healthcare quality


  • In total, they found 886 performance measures, the majority of which aligned with the Equitable High-Quality Care and Equitable Access to Care domains and few aligning with the Collaboration and Partnerships domain. Total number of measures found, examples and descriptions of measures aligned to their domains and subdomains include:
  • Collaboration and Partnerships – 7 total measures found; Example 1 (under Community and health system linkages subdomain) – Assessment of Integrated Care: Total Score for the “Integrated Services and Patient and Family-Centeredness” Characteristics on the Site Self Assessment Evaluation Tool – This measure is used to assess the total score for the “Integrated Services and Patient and Family Centeredness” characteristics on the Site Self Assessment (SSA) Evaluation Tool;
    Due to lack of measures, the following types of measures are warranted as mapped to their subdomains: 1) Collaboration across health and nonhealthy sectors – A measure that assesses the number of partnerships and active projects with nonhealthy sector organizations (e.g., schools, transportation, environment, food); 2) Build and sustain social capital and social cohesion – A measure or measures that assess the following connection to community programs, involvement in neighborhoods improvement programs, involvement in neighborhood safety, personal safety programs involvement in financial literacy, retirement, homeownership programs, partnerships between healthcare systems and schools, and outreach to marginalized communities/communities living in fear of discrimination or deportation
  • Culture of Equity – 38 total measures found, many of which are endorsed by the National Quality Forum;
    Example 1 (under cultural competency): Language services measure derived from language services domain of the C-CAT – 0-100 measure of language services related to patient centered communication, derived from items on the staff and patient surveys of the Communication Climate
    Assessment Toolkit (C-CAT); Example 2 (under cultural competency): Clinician/Group’s Cultural
    Competence Based on the CAHPS® Cultural Competence Item Set – These measures are based
    on the CAHPS Cultural Competence Item Set, a set of supplemental items for the CAHPS Clinician/Group Survey
    Due to lack of measures, the follow types of measures are warranted as mapped to their subdomains: 1) Equity is high priority – A measure that assesses whether health/healthcare equity is explicitly mentioned in institution’s mission statement and/or strategic plan; 2) Equity is high priority – A measure that assesses whether an institution has released statements, comment letters, etc. that explicitly discuss the impact of local/state/federal actions on community health and health inequities; and 3) Cultural competency – A measure that assesses the extent to which underrepresented groups are present at all levels of the organization (e.g., board, C-suite, support staff)
  • Structure for Equity – 46 measures total, many of which relate to clinical data collection
    Example 1 (under collection of data to monitor the outcomes of individuals with social risk factors): L1A: Screening for Preferred Spoken Language for healthcare – This measure is used to assess
    the % of patient visits and admissions where preferred spoken language for healthcare is screened and recorded. Access to and availability of patient language preference is critical for
    providers in planning care. This measure provides information on the extent to which patients are asked about the language they prefer to receive care in and the extent to which this information is recorded; Example 2 (under population health management): Adult Current Smoking Prevalence – %age of adult (age 18 and older) U.S. population that currently smokes. The measure is stratified by geography
    Due to lack of measures, the follow types of measures are warranted as mapped to their subdomains: 1) Collection of data to monitor the outcomes of individuals with social risk factors – A measure that assesses the number of individuals enrolled in a health plan during a measurement year for one or more months that has completed a survey with key questions such as income, home ownership, education, race/ethnicity, household size and a measure assessing use of the ICD-10 Z codes for factors influencing health status; and 2) Population health management – A set of measures that assess hospitalizations and readmissions, emergency room use, frequency and intensity of office visits, medication adherence and persistence, emergence of condition-related adverse events, and existence of co-morbidities and other diagnoses by social risk factors. Outcomes should be stratified by key social and behavioral risk factors, such as mental health conditions, alcohol/drug/substance abuse, and other risk factors
  • Equitable Access to Care – 40 measures total
    Example 1 (convenience): Patient-Centered Medical Home Patients’ Experiences – %age of parents or guardians who reported how often they were able to get the care their child needed from their child’s provider’s office during evenings, weekends, or holidays; Example 2 (availability) – Medicare Beneficiaries’ Ambulatory Care Sensitive Condition (ACSC) Hospitalizations Hospitalization Rate per 1,000 Medicare Beneficiaries – The number of discharges for ACSC in a county divided by the number of Medicare beneficiaries in a county multiplied by 1,000. The primary independent variable of interest is the number of primary care physicians; Example 3 (accessibility)L HCBS CAHPS Measure (5 of 19): Transportation to Medical Appointments – Transportation to medical appointments: Top-box score composed of 3 survey items
    Due to lack of measures, the follow types of measures are warranted as mapped to their subdomains: 1) Availability – A measure that assesses the number of primary care visit slots held for same-day appointments or drop-in access and a measure that assesses the number of days to get an appointment; 2) Accessibility – A measure that assesses the total number of outpatient or clinic practice locations (weighted by visit volume) within one block of a public transportation stop; 3) Affordability – A measure that assesses the number of services (weighted by dollar value) billed on the basis of a sliding scale linked to patient income, a patient-reported measure that assesses the level of patients’ satisfaction with their healthcare costs, and a CMS cost-related medication nonadherence scale; and 4) Convenience – A measure that assesses the number of appointments with wait times of 15 minutes or less, as reported by patients or patient caregivers
  • Equitable High-Quality Care – 755 total measures
    Example 1 (evidence-based interventions to reduce disparities): Drug Education on All Medications Provided to Patient/Caregiver During Short Term Episodes of Care – %age of short-term home- health episodes of care during which patient/caregiver was instructed on how to monitor the effectiveness of drug therapy, how to recognize potential adverse effects, and how and when to report problems; Example 2 (evidence-based interventions to reduce disparities): Depression Care: %age of Patients 18 Years of Age or Older with Major Depression or Dysthymia Who Demonstrated a Response to Treatment 12 Months (+/- 30 Days) After an Index Visit – This measure is used to assess the %age of patients 18 years of age or older with major depression or dysthymia who demonstrated a response to treatment 12 months (+/- 30 days) after an index visit. Due to lack of measures, the follow types of measures are warranted as mapped to their subdomains: 1) Person- and family-centeredness: A measure that assesses the number of adults (>18 years of age) with a documented shared decision making discussion with care provider (useful if had claim encounter code that could be submitted). Questions from the CAHPS survey could potentially be used to fill this gap; 2) Social risk factors addressed in outcome performance measures – A measure that assesses the number of patients (>18 years of age) with documented social risk factor assessment in medical record and outcome measures (such as complications of surgery) with results stratified by patients with and without social risk factor; and 3) Effective healthcare interventions to reduce disparities – A measure that assesses the number of patients with community referral, case
    management referral, consultation for social work/social services in both the pediatric and adult population

Key takeaways/implications

  • There are 5 key findings: 1) The majority of research focuses on overall improvements of outcomes in populations that are socially at risk (in absolute terms), rather than improving outcomes relative to a socially privileged reference group (e.g., white v. African American); 2) A paucity of health equity-focused implementation science studies is a barrier to the uptake of evidence-based interventions into routine healthcare, clinical, organizational or policy contexts; 3) Existing interventions largely focus on patient education, lifestyle modification and culturally tailored programs with few addressing how to improve health systems for populations with social risk factors; 4) Most interventions target disparities based on race and ethnicity with few addressing disparities based on disability status, income, social relationships, health literacy and residential and community context; and 5) Many interventions could potentially reduce disparities among multiple conditions, but are usually implemented and evaluated for addressing disparities in 1 condition. Also, many interventions could address disparities related to more than 1 social risk factor
  • There are 4 key areas of consideration for identification and prioritization of reducing health disparities: 1) Prevalence (e.g., how prevalent is the condition among populations with social risk factors?); 2) Size of the disparity (e.g., how large is the gap in quality, access, and out outcome between the group with social risk factors and the group with the highest quality ratings for the measure?); 3) Strength of the evidence (e.g., how strong is the evidence linking improvement in performance on the measure to improved outcomes in the population with social risk factors?); and 4) Ease and feasibility of improvement (e.g., is the measure actionable among the population with social risk factors?)
  • An organization’s ability to identify disparities depends on their capacity to collect information on an individual’s sociodemographic characteristics. Once collected, organizations should routinely stratify performance measures to monitor disparities
  • There is a need for further investment and research in better understanding the mediators of disparities. Organizations can look to programs and initiatives like RWJF’s Finding Answers: Solving Disparities Through Payment and Delivery Systems Reform, the National Academy of Medicines’ community-based solutions to promote health equity, PCORI’s landscape review of options to reduce disparities in cardiovascular disease, and the Institute for Healthcare Improvement’s white paper to improve health equity in the communities they serve
  • There is a need for both stratified performance measures that directly measure whether results are equitable between different groups, and other disparity measures that can help guide efforts to improve systems of care such as whether structures are in place that have been demonstrated to reduce disparities
  • The use of measures can incentivize reduction of disparities by more transparently showing disparities, potential use for accreditation, and interventions to reduce disparities could be prioritized for implementation in public reporting and value-based purchasing
  • Public and private payers could also adjust payments to providers based on social risk factors and consider increasing payments for hospital services based on social risk factors
  • Challenges to identifying disparities-sensitive measures include the limited nature of data on social risk factors, and need to ensure patient privacy potentially limiting numbers. However, when numbers are small and difficult to collect and stratify, oversampling and multiyear pooling techniques should be considered
  • There are 10 recommendations that emerged from the workshop: 1) Collect social risk factor data by investing in necessary infrastructure (e.g., greater use of ICD-10 codes for factors addressing health status) and collecting neighborhood-level data on social risk factors; 2) Use and prioritize stratified health equity outcome measures by first conducting a needs assessment to identify the extent to which they are meeting goals and then consider as a whole to make progress; 3) Prioritize measures in the domains of Equitable Access and Equitable High-Quality Care for accountability purposes; 4) Invest in preventive and primary care for patients with social risk factors; 5) Redesign payment models to support health equity (e.g., upfront payments to fund infrastructure for achieving equity and addressing the social determinants of health); 6) Link health equity measures to accreditation programs (e.g., the National Committee for Quality Assurance); 7) Support outpatient and inpatient services with additional payment for patients with social risk factors; 8) Ensure organizations disproportionately serving individuals with social risk can compete in value-based purchasing programs; 9) Fund care delivery and payment reform demonstration projects to reduce disparities; and 10) Assess economic impact of disparities from multiple perspectives