Equity In Health Care Delivery Research Articles

Minding the Safety Gap: The Road Towards Global Equity in Health Care Delivery

Minding the Safety Gap: The Road Towards Global Equity in Health Care Delivery

Medical Equity: The Eventual Goal of Health Care

Medical equity is the fundamental principle that all individuals should have equal access to high-quality healthcare services, regardless of their race, ethnicity, gender, socioeconomic status, or geographic location. Achieving medical equity is essential for improving health outcomes and reducing disparities in healthcare delivery. This goal requires addressing systemic barriers such as discrimination, stigma, and lack of access to resources that prevent marginalized populations from receiving appropriate care. Implementing policies and programs that promote medical equity will help ensure that everyone has the opportunity to lead a healthy life. By prioritizing equity in healthcare delivery, we can work towards creating a more just and inclusive society where every individual has the opportunity to achieve optimal health and well-being.

Race, Ethnicity, and Other Patient and Clinical Encounter Characteristics Associated with Patient Experiences of Access to Care.

The Press Ganey (PG) Outpatient Medical Practice Survey measures patients' experiences of healthcare access in the U.S. We aimed to identify differences in experiences of access to care by patient race, ethnicity, and other sociodemographic characteristics, an important first step in informing health policy and ensuring equitable healthcare delivery. We performed a cross-sectional analysis of PG surveys for adult outpatient visits within the University of Pennsylvania Health System from 2014-2017, including 119,373 unique patients. Compared with White patients, Black (odds ratio [OR] 0.84; 95% confidence interval [CI] 0.80-0.87), Asian (OR 0.62; 95% CI 0.58-0.66), and other/unknown race patients (OR 0.83; 95% CI 0.72-0.94) were each less likely to report the maximum score for timely access to care. Patients of all minoritized groups, as well as those whose primary language was not English, reported lower scores in secondary access measures related to communication and respect, compared to White and primarily English-speaking patients, respectively. Efforts to improve the experience of access to care among racial and ethnic minoritized patients are imperative to achieve equity in healthcare delivery.

All talk…only a little action: a reflection on embedding equity into integrated care models in Ontario, Canada

Background: Ontario Health Teams (OHTs) are a recently introduced model of delivery intended to integrate services to deliver connected care to defined populations in Ontario, Canada. The Quadruple Aim advocates for improving patient experience, reducing cost, advancing population health, and improving the provider experience; it is meant to be a guide for OHTs for performance outcomes and as a framework for evaluation and reporting. The Quintuple Aim, incorporating an added focus on health equity, has recently been introduced to OHTs, where equity is also built into continuous quality improvement requirements. As embedded OHT research fellows, we recognize our key role in supporting equity in healthcare delivery and programs. However, we also observe the challenges to generating actionable initiatives to integrate equity into OHTs.
 Objective: The objective of this presentation is to describe equity initiatives being incorporated in four OHTs in Ontario, Canada and to identify the barriers and facilitators at the micro, meso and macro levels. This presentation is aimed at those involved in integrated care research, policy, practice, and education.
 Methods: We will use a multiple case study design to describe the contexts of four integrated care models representing large, mid, and small urban regions of the province. This work is guided by the Rainbow Model for Integrated Care, which conceptualizes different domains of integrated care. We will include multiple data sources from each OHT, including key documents, formal and informal community partnerships, the level and nature of engagement with equity-deserving groups in governance processes, the extent to which equity is emphasized in strategic plans and other documents, and the resources available, we share insights gleaned on barriers and facilitators to applying an equity lens. 
 Key Results: We identify challenges related to data availability for health equity decision making and health systems planning. Specifically, difficulties exist in accessing meaningful and linked data to understand OHT attributed populations; these difficulties are compounded when seeking data specific to equity deserving groups and when attempting to link equity relevant indicators to health system indicators. Furthermore, meaningful engagement with equity deserving groups in order to build relationships requires time and resources that are difficult to source; such engagement is particularly challenging in an environment of limited financial resources, where frequent reporting and pressure to quickly deliver outcomes is emphasized. OHTs are collaborative governance models composed of representation from member organizations, patients, and academics; this collaborative approach to governance can be a facilitator to embedding equity deserving groups into the structure of OHTs.
 Next Steps: Ontario Health Teams require support in creating comprehensive equity approaches that are specific to the needs of their communities and teams; further work is needed to better understand the needs of OHTs in this regard.

Clinicians' Perspectives on Equitable Health Care Delivery in Group Well-Child Care.

To explore clinicians' perspectives about the impact of group well-child care (GWCC) on equitable health care delivery. In this qualitative study, we conducted semistructured interviews with clinicians engaged in GWCC recruited via purposive and snowball sampling. We first conducted a deductive content analysis using constructs from Donabedian's framework for health care quality (structure, process, and outcomes) followed by inductive thematic analysis within these constructs. We completed 20 interviews with clinicians who deliver or research GWCC in 11 institutions across the United States. Four major themes around equitable health care delivery in GWCC emerged from clinicians' perspectives: 1) shifts in power dynamics (process); 2) enabling relational care, social support, and a sense of community (process, outcome); 3) centering multidisciplinary care delivery around patient and family needs (structure, process, and outcomes); and 4) unaddressed social and structural barriers limit patient and family participation. Clinicians perceived that GWCC enhances equity in health care delivery by shifting hierarchies in clinical visits and promoting relational, patient, and family-centered care. However, potential opportunities exist to further address provider implicit bias in group care delivery and structural inequities at the level of the health care institution. Clinicians underscored the need to address barriers to participation so that GWCC can more fully enhance equitable health care delivery.

Refining 2SVCA method for measuring telehealth accessibility of primary care physicians in Baton Rouge, Louisiana

Equity in health care delivery is a longstanding concern of public health policy. Telehealth is considered an important way to level the playing field by broadening health services access and improving quality of care and health outcomes. This study refines the recently developed “2-Step Virtual Catchment Area (2SVCA) method” to assess the telehealth accessibility of primary care in the Baton Rouge Metropolitan Statistical Area, Louisiana. The result is compared to that of spatial accessibility via physical visits to care providers based on the popular 2-Step Floating Catchment Area (2SFCA) method. The study shows that both spatial and telehealth accessibilities decline from urban to low-density and then rural areas. Moreover, disproportionally higher percentages of African Americans are in areas with higher spatial accessibility scores; but such an advantage is not realized in telehealth accessibility. In the study area, absence of broadband availability is mainly a rural problem and leads to a lower average telehealth accessibility than physical accessibility in rural areas. On the other side, lack of broadband affordability is a challenge across the rural-urban continuum and is disproportionally associated with high concentrations of disadvantaged population groups such as households under the poverty level and Blacks.

A Policy Framework for the Growing Influence of Private Equity in Health Care Delivery

This Viewpoint details how and why improved oversight of private equity acquisition of physician practices and hospitals is needed to mitigate the effects on health care costs, clinicians’ jobs, and patients’ access to care.

EHealth Literacy and Patient Portal Use and Attitudes: Cross-sectional Observational Study.

Throughout the COVID-19 pandemic, patient portals have become more widely used tools of patient care delivery. However, not all individuals have equivalent access or ability to use patient portals. The aim of this study is to evaluate the relationships between eHealth literacy (eHL) and patient portal awareness, use, and attitudes among hospitalized patients. Inpatients completed patient portal surveys; eHL was assessed (eHealth Literacy Scale). Multivariable logistic regression analyses adjusted for age, self-reported race, gender, and educational attainment were completed with significance at P<.006 (Bonferroni correction). Among 274 participants, most identified as Black (n=166, 61%) and female (n=140, 51%), mean age was 56.5 (SD 16.7) years, and 178 (65%) reported some college or higher educational attainment. One-quarter (n=79, 28%) had low eHL (mean 27, SD 9.5), which was associated with lower odds of portal access awareness (odds ratio 0.11, 95% CI 0.05-0.23; P<.001), having ever used portals (odds ratio 0.19, 95% CI 0.10-0.36; P<.001), less perceived usefulness of portals (odds ratio 0.20, 95% CI 0.10-0.38; P=.001), and lower likelihood of planning to use portals in the coming years (odds ratio 0.12, 95% CI 0.06-0.25; P<.001). As time through the COVID-19 pandemic passed, there was a trend toward increased perceived usefulness of patient portals (53% vs 62%, P=.08), but average eHL did not increase through time (P=.81). Low eHL was associated with less awareness, use, and perceived usefulness of portals. Perceived usefulness of portals likely increased through the COVID-19 pandemic, but patients' eHL did not. Interventions tailored for patients with low eHL could ensure greater equity in health care delivery through the COVID-19 pandemic.

Can digital finance mitigate trust issues for chronically ill patients because of relative deprivation of income?

The relative deprivation of income among chronically ill patients may create a perception of inequity in their access to quality healthcare, which may lead to a decline in patients' trust and further increases the burden of chronic diseases. Digital finance could be the antidote. To promote equity in healthcare delivery, this study explores the mitigating effect of digital finance by elucidating the relationship between relative deprivation of income and chronically ill patients' trust. Using data from the China Family Panel Study, a Poisson regression model was applied to assess the effect of relative deprivation of income on chronically ill patients' trust. A marginal effect analysis was used to verify the effect and a two-stage least squares method was used to test robustness. Chronically ill patients' trust was at a medium level (5.98 ± 2.05). Relative deprivation of income significantly reduced patients' trust (β=-0.056, p < 0.1). The digital finance had a positive effect on patients' trust (β=0.035, p < 0.01) and alleviated the negative effect of relative deprivation of income on patients' trust (β=0.105, p < 0.01). The instrumental variable estimation results confirmed the robustness of the benchmark regression results. The inequity resulting from relative deprivation of income undermines patients' trust. Digital finance has a long-term effect on alleviating perception of inequity among chronically ill patients. The government should promote the integration of digital finance and smart healthcare to enhance patients' trust and contribute to equality in healthcare delivery. Limitations include self-reported data and an insufficient correlation between selected indicators and healthcare services.

AcceSS and Equity in Transplantation (ASSET) New Zealand: Protocol for population-wide data linkage platform to investigate equity in access to kidney failure health services in New Zealand.

BackgroundKidney transplantation is considered the ideal treatment for most people with kidney failure, conferring both survival and quality of life advantages, and is more cost effective than dialysis. Yet, current health systems may serve some people better than others, creating inequities in access to kidney failure treatments and health outcomes. AcceSS and Equity in Transplantation (ASSET) investigators aim to create a linked data platform to facilitate research enquiry into equity of health service delivery for people with kidney failure in New Zealand.MethodsThe New Zealand Ministry of Health will use patients’ National Health Index (NHI) numbers to deterministically link individual records held in existing registry and administrative health databases in New Zealand to create the data platform. The initial data linkage will include a study population of incident patients captured in the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), New Zealand Blood Service Database and the Australia and New Zealand Living Kidney Donor Registry (ANZLKD) from 2006 to 2019 and their linked health data. Health data sources will include National Non-Admitted Patient Collection Data, National Minimum Dataset, Cancer Registry, Programme for the Integration of Mental Health Data (PRIMHD), Pharmaceutical Claims Database and Mortality Collection Database. Initial exemplar studies include 1) kidney waitlist dynamics and pathway to transplantation; 2) impact of mental illness on accessing kidney waitlist and transplantation; 3) health service use of living donors following donation.ConclusionThe AcceSS and Equity in Transplantation (ASSET) linked data platform will provide opportunity for population-based health services research to examine equity in health care delivery and health outcomes in New Zealand. It also offers potential to inform future service planning by identifying where improvements can be made in the current health system to promote equity in access to health services for those in New Zealand.

Shattering Glass Ceilings: Three Black Women Surgeons Ascend to Chairs of Departments of Surgery.

Shattering Glass Ceilings: Three Black Women Surgeons Ascend to Chairs of Departments of Surgery.

Implementation and first evaluation of a nationwide oncology navigation program.

e13532 Background: Navigation in oncology has demonstrated benefits for people at risk for or diagnosed with cancer. These include a shorter time to diagnosis and start of treatment, better adherence to recommended care, and improved quality of life. Implementing a nurse navigation program can be challenging in developing countries, especially when involving nationwide health care networks. This study describes the implementation of a pioneering oncology navigation program in Brazil. Methods: Rede D’Or São Luiz (RDSL) is Brazil's largest integrated private health care network, comprising 63 general tertiary hospitals and 50 oncology clinics in 13 states. In 2018 a comprehensive oncology navigation program was started. The first phase focused on identifying suspected or diagnosed cancer patients who attended general hospitals to improve their care coordination. A trained nurse was allocated to support each hospital, supervised by a regional nurse coordinator and physician. A web-based system was created, by the participants, to integrate data collected from all hospitals. Epidemiological, social, and clinical data were obtained, including time to establish a cancer diagnosis and start of treatment. A national virtual meeting is held every two weeks to present anonymous data, compare results, and create solutions to address national and local barriers. Results: From 2018 to 2022, a total of 25,862 potential patients were identified by the navigation program. Of these, 10,951 ended with a diagnosis of cancer. Currently 32 hospitals from 6 different cities are involved. In the beginning, most patients (38%) were identified at Inpatient Clinical Units, after a cancer diagnosis. Over time the number of patients identified at surgical and diagnostic centers increased from 365 to 589 and 282 to 542, respectively. Cancer epidemiology was comparable to Brazilian data. Most patients had breast cancer (13%), followed by prostate cancer (12%) and colon cancer (7%). These numbers were slightly different according to hospital location. The number of patients recruited at Emergency rooms is still low (9%) comparable to other facilities. A total of 2,391 patients required an inpatient treatment approach, supported by the oncology team. Conclusions: The goal of the navigation program is to reduce cancer morbidity and mortality by eliminating barriers to timely access to cancer care, which may be financial, social, logistical, or related to communication and equity of health care delivery. These results show that RDSL National Oncology Navigation Program is feasible. After this implementation phase, a comprehensive database was built to guide care coordination, and there was a shift to earlier identification of potential patients. In the future, we expect that data collected from this project may help individual patients and families but also address cancer care disparities over the country.

Acceptability, Feasibility, and Quality of Telehealth for Adolescent Health Care Delivery During the COVID-19 Pandemic: Cross-sectional Study of Patient and Family Experiences.

BackgroundData regarding the acceptability, feasibility, and quality of telehealth among adolescents and young adults (AYA) and their parents and caregivers (caregivers) are lacking.ObjectiveThe aim of this study was to assess the noninferiority of telehealth versus in-person visits by comparing acceptability with respect to efficiency, effectiveness, equity, patient-centeredness, and confidentiality.MethodsCross-sectional web-based surveys were sent to caregivers and AYA following video visits within an Adolescent Medicine subspecialty clinic in May-July 2020. Proportions of AYA and caregivers who rated telehealth as noninferior were compared using chi-squared tests. Feasibility was assessed via items measuring technical difficulties. Deductive thematic analysis using the Institute of Medicine dimensions of health care quality was used to code open-ended question responses.ResultsSurvey response rates were 20.5% (55/268) for AYA and 21.8% (123/563) for caregivers. The majority of the respondents were White cisgender females. Most AYA and caregivers rated telehealth as noninferior to in-person visits with respect to confidentiality, communication, medication management, and mental health care. A higher proportion of AYA compared to caregivers found telehealth inferior with respect to confidentiality (11/51, 22% vs 3/118, 2.5%, P<.001). One-quarter (14/55) of the AYA patients and 31.7% (39/123) of the caregivers reported technical difficulties. The dominant themes in the qualitative data included advantages of telehealth for efficiency and equity of health care delivery. However, respondents’ concerns included reduced safety and effectiveness of care, particularly for patients with eating disorders, owing to lack of hands-on examinations, collection of vital signs, and laboratory testing.ConclusionsTelehealth was highly acceptable among AYA and caregivers. Future optimization should include improving privacy, ameliorating technical difficulties, and standardizing at-home methods of obtaining patient data to assure patient safety.

Historicizing medical drones in Africa: a focus on Ghana

While the genesis of the drone technology is not clear, one thing is ideal: it emerged as a military apparatus and gained much attention during major wars, including the two world wars. Aside being used in combats and to deliver humanitarian services, drones have also been used extensively to kill both troops and civilians. Revolutionized in the 19th century, the drone technology was improved to be controlled as an unmanned aerial devices to mainly target troops. A new emerging field that has seen the application of the drone technology is the healthcare sector. Over the years, the health sector has increasingly relied on the device for timely transportation of essential articles across the globe. Since its introduction in health, scholars have attempted to address the impact of drones on healthcare across Africa and the world at large. Among other things, it has been reported by scholars that the device has the ability to overcome the menace of weather constraints, inadequate personnel and inaccessible roads within the healthcare sector. This notwithstanding, data on drones and drone application in Ghana and her healthcare sector in particular appears to be little within the drone literature. Also, few attempts have been made by scholars to highlight the use of drones in African countries. By using a narrative review approach, the current study attempts to address the gap above. Using this approach, a thorough literature search was performed to locate and assess scientific materials that focus on the application of drones in the military field and in the medical systems of Africa and Ghana in particular. With its sole responsibility to deliver items, stakeholders of health across several parts of the world have relied on drones to transport vital articles to health centers. Countries like Senegal, Madagascar, Rwanda and Malawi encouraged Ghana to consider the application of drones in her mainstream healthcare delivery. Findings from the study have revealed that Ghana’s adoption of the drone policy has enhanced the timely delivery of products such as test samples, blood and Personal Protective Equipment to various health centres and rural areas in particular. Drones have contributed to the delivery of equity in healthcare delivery in Ghana. We conclude that with the drone policy, the continent has the potential to record additional successes concerning the over-widened gap in healthcare between rural and urban populations.

Equity in clinical practice requires organisational and system-level change – The role of nurse leaders

ABSTRACT Background In the International Year of the Nurse and Midwife 2020, nurses in Australia and around the world are being encouraged to lend their voices to lead change. The COVID-19 global health crisis has highlighted the critical role of nurses in our community in ensuring that the challenges to our health care system are being met and overcome. It has also brought attention to existing health inequities in our community, in particular the poorer health of refugees, some culturally and linguistically diverse communities and Aboriginal and Torres Strait Islander peoples. Aim To call on nurses and nurse leaders to take greater action to improve health equity. Methods This paper presents a discussion with regard to the importance of equitable and safe clinical practice and the urgent need to address organisational and system-level barriers to the provision of equitable health care. Findings Clinicians’ abilities and capacities to provide equitable care is ultimately shaped by health care organisations and the broader historical, political, social and economic context of our community. Discussion Equity should not only be reflected in clinical practice, but also in organisational policies and procedures, embedded in key performance indicators and supported by adequate funding and resources. Conclusion Systemic inadequacies are likely to be further amplified during times when the health system is under additional pressure. Nurses and nurse leaders should take this opportunity to reflect upon the integral role they play in addressing organisational and system-level change to ensure equity in health care delivery. We call on nurse leaders and the nursing profession to lead us all to a more equitable health care system and society.

Hospital efficiency and equity in health care delivery: A study based in China

Hospital efficiency and equity in health care delivery are two enduring research topics. Yet little research has been done to examine the relationship between them. This paper studies the impact of hospital efficiency on equity in health care delivery based on a proprietary dataset of hospital characteristics and 630,000 inpatient records from 149 public hospitals in a representative Chinese city. To measure the hospitals' efficiencies, this study takes the hospitals' operational features and case-mix indexes into account, and computes the efficiency levels using data envelopment analysis with bootstrapping. Through regressions that control for a variety of the patients’ personal characteristics (e.g., age, disease, residence, hospital visit frequency), this study shows that the gap between hospitalization expenses of urban and rural inpatients in more efficient hospitals is smaller than those in less efficient hospitals. Thus efficiency enhances equity in expenditure between urban and rural patients. But the dwindling urban-rural gap in expenditure is achieved by raising the spending of rural patients, thereby undermining their access to health care. This pattern is more conspicuous in large and sophisticated high-tier hospitals. Further analysis shows that hospital efficiency impacts equity of health care delivery by inducing different lengths of stay and uncovered parts of total expenditure for urban and rural groups. The findings imply that an efficiency-oriented health care policy may lead to social benefit loss.

Advancing Social Mission in Nursing Education: Recommendations From an Expert Advisory Board

Social mission refers to a set of concepts and perspectives that promote health equity in health care delivery and within health professions. Little is known about social mission within the context of nursing education. This article clarifies the role of social mission in nursing education, offers current applications, and identifies future opportunities to maximize social mission within nursing to foster a more just culture of health. A multidisciplinary advisory board of experts in nursing education convened to review pertinent literature, current case exemplars, and craft a conceptual framework of social mission in nursing education. The resulting framework consisted of three action-oriented domains to implement social mission into nursing education: board accreditation, curriculum building and faculty training, and developing institutional culture. Successful implementation of social mission into nursing education, and subsequently the nursing workforce, offers the opportunity to further embed equity into health care. [J Nurs Educ. 2020;59(8):433-438.].

Urban and rural differences in geographical accessibility to inpatient palliative and end-of-life (PEoLC) facilities and place of death: a national population-based study in England, UK

BackgroundLittle is known about the role of geographic access to inpatient palliative and end of life care (PEoLC) facilities in place of death and how geographic access varies by settlement (urban and rural). This study aims to fill this evidence gap.MethodsIndividual-level death data in 2014 (N = 430,467, aged 25 +) were extracted from the Office for National Statistics (ONS) death registry and linked to the ONS postcode directory file to derive settlement of the deceased. Drive times from patients’ place of residence to nearest inpatient PEoLC facilities were used as a proxy estimate of geographic access. A modified Poisson regression was used to examine the association between geographic access to PEoLC facilities and place of death, adjusting for patients’ socio-demographic and clinical characteristics. Two models were developed to evaluate the association between geographic access to inpatient PEoLC facilities and place of death. Model 1 compared access to hospice, for hospice deaths versus home deaths, and Model 2 compared access to hospitals, for hospital deaths versus home deaths. The magnitude of association was measured using adjusted prevalence ratios (APRs).ResultsWe found an inverse association between drive time to hospice and hospice deaths (Model 1), with a dose–response relationship. Patients who lived more than 10 min away from inpatient PEoLC facilities in rural areas (Model 1: APR range 0.49–0.80; Model 2: APR range 0.79–0.98) and urban areas (Model 1: APR range 0.50–0.83; Model 2: APR range 0.98–0.99) were less likely to die there, compared to those who lived closer (i.e. ≤ 10 min drive time). The effects were larger in rural areas compared to urban areas.ConclusionGeographic access to inpatient PEoLC facilities is associated with where people die, with a stronger association seen for patients who lived in rural areas. The findings highlight the need for the formulation of end of life care policies/strategies that consider differences in settlements types. Findings should feed into local end of life policies and strategies of both developed and developing countries to improve equity in health care delivery for those approaching the end of life.

Geographic variation in potentially avoidable hospitalizations in France.

Potentially avoidable hospitalizations are studied as an indirect measure of access to primary care. Understanding the determinants of these hospitalizations can help improve the quality, efficiency, and equity of health care delivery. Few studies have tackled the issue of potentially avoidable hospitalizations in France, and none has done so at the national level. We assessed disparities in potentially avoidable hospitalizations in France in 2012 and analyzed their determinants. The standardized rate of potentially avoidable hospitalizations ranged from 0.1 to 44.4 cases per 1,000 inhabitants, at the ZIP code level. Increased potentially avoidable hospitalizations were associated with higher mortality, lower density of acute care beds and ambulatory care nurses, lower median income, and lower education levels. This study unveils considerable variation in the rate of potentially avoidable hospitalizations in spite of France's mandatory, publicly funded health insurance system. In addition to epidemiological and sociodemographic factors, this study suggests that primary care organization plays a role in geographic disparities in potentially avoidable hospitalizations that might be addressed by increasing the number of nurses and enhancing team work in primary care. Policy makers should consider measuring potentially avoidable hospitalizations in France as an indicator of primary care organization.

Pharmacoeconomics and developing nations

The scarcity of resources within both industrialized and developing nations has catalyzed the adoption of more formalized approaches to support decisionmaking, particularly within healthcare. In many instances, however, the unique aspects present within developing countries may not permit the direct translation of pharmacoeconomic guidelines or recommendations from high-income economies. The purpose of this paper is to delineate the key attributes that differentiate pharmacoeconomics within developing nations, including the potential barriers to implementation and policy considerations involved. Through its approach to comprehensively assess costs and outcomes of technologies, pharmacoeconomic methodologies may help foster the optimal allocation of resources to improve the effectiveness, efficiency, and equity of healthcare delivery for societies worldwide.