Partnering Health Disparities Research With Quality Improvement Science in Pediatrics

Lion C, Raphael J
Source: Pediatrics
Publication Year: 2015
Population Focus: Vulnerable/disadvantaged
Demographic Group: Child, Racial and ethnic minority groups
Intervention Type: Staff design and care management
Type of Literature: White
link: https://pediatrics.aappublications.org/content/135/2/354
Abstract

Disparities in pediatric healthcare quality are well described in the literature, yet practical approaches to decreasing them remain elusive. Quality improvement (QI) approaches are appealing for addressing disparities because they offer a set of strategies by which to target modifiable aspects of care delivery and a method for tailoring or changing an intervention over time based on data monitoring. However, few examples in the literature exist of QI interventions successfully decreasing disparities, particularly in pediatrics, due to well-described challenges in developing, implementing, and studying QI with vulnerable populations or in under resourced settings. In addition, QI interventions aimed at improving quality overall may not improve disparities, and in some cases, may worsen them if there is greater uptake or effectiveness of the intervention among the population with better outcomes at baseline. In this article, the authors review some of the challenges faced by researchers and frontline clinicians seeking to use QI to address health disparities and propose an agenda for moving the field forward. Specifically, they propose that those designing and implementing disparities-focused QI interventions reconsider comparator groups, use more rigorous evaluation methods, carefully consider the evidence for particular interventions and the context in which they were developed, directly engage the social determinants of health, and leverage community resources to build collaborative networks and engage community members. Ultimately, new partnerships between communities, providers serving vulnerable populations, and QI researchers will be required for QI interventions to achieve their potential related to healthcare disparity reduction.

Insights Results

Overview of article

  • This article aims to describe the rationale for disparities-focused quality improvement (QI), summarize the existing evidence regarding disparities-focused QI, discuss potential barriers to using QI to address pediatric health disparities, and provide an agenda for merging health disparities research and QI into a rigorous, patient-centered field of study and implementation
  • Disparities-focused QI should be further assessed due to the established link between healthcare quality and improvement in equity. QI includes standardized clinical pathways, benchmarking, performance incentives, public reporting, provider reminder systems and decision aids

Results

  • There are 3 paths of projected outcomes of successful QI efforts: 1) QI intervention disproportionately benefits underserved group (i.e., disparities reduced); 2) QI intervention benefits all groups at the same rate (i.e., disparities remain constant); and 3) QI intervention disproportionately benefits majority group (i.e., disparities widen)
  • As identified in a systematic study, successful interventions for pediatric QI relied on lay health outreach workers, home visits, and integration of the intervention into existing community-based organizations
  • There is a lack of evidence evaluating QI interventions’ effect on disparities, especially for children. In the literature review, only 2 QI studies specifically targeted reducing disparities. Overall, there was poor evidence to determine which interventions might reduce disparities between racial/ethnic minority patients and majority patients
  • Factors such as lack of readily available data around race/ethnicity, existing structures like pay-for-performance programs, and potentially limited engagement from minority patients may drive the lack of QI studies focusing on reducing health disparities
  • There are 5 focus areas to advance QIs addressing of health equity: 1) Consideration of comparators/tailoring QIs to high-risk populations – this would address inconsistency in availability of baseline race/ethnicity data, lack of benchmarks for what constitutes a clinically important disparity reduction, underpowered nature of QI studies to detect differences, and lack of readily available nonminority reference groups. This approach may increase the efficiency and effectiveness of interventions; 2) Increasing the rigor of QI interventions addressing health disparities – Consider using robust evaluation methods like interrupted time series analysis, statistical process control or stepped wedge design to effectively evaluate effectiveness in real-world settings. This also helps to separate the intervention from contextual factors; 3) Understanding the context and mechanisms of the intervention and its site – Researchers should carefully consider the care structure, processes, and outcomes currently in place in their healthcare setting, the context surrounding those care delivery attributes, how those compare with the ones described in the study; and whether they differ for different groups of patients; 4) Engagement of social determinants of health in QI – Increasingly, researchers are assessing community factors (e.g., geography, housing) to inform QI efforts and improve community health at multiple levels, beyond those normally directly involved in healthcare access or delivery; and 5) Leveraging community resources and capacity to overcome resource gaps – QI in underserved areas may require significant modification and adaptation of existing interventions, careful attention to both financial and intellectual resources, and creative approaches to funding and implementation

Key takeaways/implications

  • With improving quality established as a central tenet of ongoing healthcare system redesign, rigorously conducted QI interventions represent a core strategy toward achieving the triple aim of enhancing patient experience, lowering cost, and improving population health. For underserved children, QI holds promise as a method by which to address longstanding inequities in care delivery
  • Successful integration of QI and health disparities research will require reconsideration of comparators; improved methodological rigor in selecting and evaluating interventions; increased consideration of context; proactive attention to social determinants of health; and leveraging of community resources. More practically, it will necessitate new collaborative partnerships between QI researchers in highly resourced settings and frontline providers committed to improving the care of minority populations
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